[{"Code":"0001U","CodeDescription":"RBC DNA HEA 35 AG 11 BLD GRP WHL BLD CMN ALLEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0003U","CodeDescription":"ONC OVARIAN ASSAY 5 PROTEINS SERUM ALG SCOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0007U","CodeDescription":"RX TEST PRESUMPTIVE URINE W\/DEF CONFIRMATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0007U","CodeDescription":"RX TEST PRESUMPTIVE URINE W\/DEF CONFIRMATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0007U","CodeDescription":"RX TEST PRESUMPTIVE URINE W\/DEF CONFIRMATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0007U","CodeDescription":"RX TEST PRESUMPTIVE URINE W\/DEF CONFIRMATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0007U","CodeDescription":"RX TEST PRESUMPTIVE URINE W\/DEF CONFIRMATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00100","CodeDescription":"ANESTHESIA SALIVARY GLANDS WITH BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00102","CodeDescription":"ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00103","CodeDescription":"ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00104","CodeDescription":"ANESTHESIA ELECTROCONVULSIVE THERAPY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00120","CodeDescription":"ANESTHESIA EXTERNAL MIDDLE & INNER EAR W\/BX NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00124","CodeDescription":"ANES EXTERNAL MIDDLE & INNER EAR W\/BX OTOSCOPY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00126","CodeDescription":"ANES XTRNL MID & INNER EAR W\/BX TYMPANOTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00140","CodeDescription":"ANESTHESIA EYE NOT OTHERWISE SPECIFIED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00142","CodeDescription":"ANESTHESIA EYE LENS SURGERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00144","CodeDescription":"ANESTHESIA EYE CORNEAL TRANSPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00145","CodeDescription":"ANESTHESIA EYE VITREORETINAL SURGERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00147","CodeDescription":"ANESTHESIA EYE IRIDECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00148","CodeDescription":"ANESTHESIA EYE OPHTHALMOSCOPY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0014M","CodeDescription":"LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0014M","CodeDescription":"LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0014M","CodeDescription":"LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0014M","CodeDescription":"LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0014M","CodeDescription":"LIVER DS ALYS 3 BIOMARKERS IA SRM PROGNOSTIC ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00160","CodeDescription":"ANESTHESIA NOSE & ACCESSORY SINUSES NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00162","CodeDescription":"ANES NOSE & ACCESSORY SINUSES RADICAL SURGERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00164","CodeDescription":"ANES NOSE & ACCESSORY SINUSES BIOPSY SOFT TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0016U","CodeDescription":"ONC HMTLMF NEO RNA BCR\/ABL1 BLD\/BNE MARROW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00170","CodeDescription":"ANESTHESIA INTRAORAL WITH BIOPSY NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00172","CodeDescription":"ANES INTRAORAL W\/BIOPSY REPAIR CLEFT PALATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00174","CodeDescription":"ANES INTRAORAL W\/BX EXC RETROPHARYNGEAL TUMOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00176","CodeDescription":"ANESTHESIA INTRAORAL W\/BIOPSY RADICAL SURGERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0017M","CodeDescription":"ONC DLBCL MRNA FLUOR PRB HYBRDZTN 20 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0017U","CodeDescription":"ONC HMTLMF NEO JAK2 MUTATION DNA BLD\/BNE MARROW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0018U","CodeDescription":"ONC THYR 10 MICRORNA SEQ +\/- RSLT MOD HI RSK MAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00190","CodeDescription":"ANESTHESIA FACIAL BONES OR SKULL NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00192","CodeDescription":"ANES FACIAL BONES\/SKULL RAD SURG W\/PROGNATHISM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00210","CodeDescription":"ANESTHESIA INTRACRANIAL PROCEDURE NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00211","CodeDescription":"ANES INTRACRANIAL CRANIOTOMY\/CRANIECTOMY HMTMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00212","CodeDescription":"ANESTHESIA INTRACRANIAL PROCEDURE SUBDURAL TAPS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00214","CodeDescription":"ANES INTRACRANIAL BURR HOLES W\/VENTRICULOGRAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00215","CodeDescription":"ANES INTRACRANIAL\/ELEVATION DEPRSD SKULL FX XDRL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00216","CodeDescription":"ANESTHESIA INTRACRANIAL VASCULAR PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00218","CodeDescription":"ANES INTRACRANIAL PROCEDURE IN SITTING POSITION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00220","CodeDescription":"ANES INTRACRANIAL CEREBROSPINAL FLUID SHUNTING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00222","CodeDescription":"ANES INTRACRANIAL ELECTROCOAGULATION ICRA NERVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0022U","CodeDescription":"TRGT GEN SEQ ALYS CCA&NONSM LNG NEO DNA&RNA 1-23","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0023U","CodeDescription":"ONC AML DNA GNTYP INT TANDEM DUP DETCJ\/NONDETCJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0026U","CodeDescription":"ONC THYR DNA&MRNA 112 GENES FNA NDUL ALG ALYS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0027U","CodeDescription":"JAK2 GENE ANALYSIS TRGT SEQ ALYS EXONS 12-15","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00300","CodeDescription":"ANES INTEG MUSC & NRV HEAD NECK&POSTERIOR TRUNK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00320","CodeDescription":"ANES ESOPH THYRD LARYNX TRACH & LYMPH NECK 1YR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00322","CodeDescription":"ANES ESOPH THYRD LARX TRACH & LYMPH NCK BX THYRD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00326","CodeDescription":"ANESTHESIA LARYNX & TRACHEA CHILDREN  LT 1 YEAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0034U","CodeDescription":"TPMT NUDT15 GENE ANALYSIS COMMON VARIANTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00350","CodeDescription":"ANESTHESIA MAJOR VESSELS NECK NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00352","CodeDescription":"ANESTHESIA MAJOR VESSELS NECK SIMPLE LIGATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0035U","CodeDescription":"NEURO CSF DETCJ PRION PRTN QUAKG CONF CONV QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0037U","CodeDescription":"TRGT GEN SEQ ALYS SLD ORGN NEO DNA 324 GENES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0038U","CodeDescription":"VITAMIN D SERUM MICROSAMPLE QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0038U","CodeDescription":"VITAMIN D SERUM MICROSAMPLE QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0038U","CodeDescription":"VITAMIN D SERUM MICROSAMPLE QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0038U","CodeDescription":"VITAMIN D SERUM MICROSAMPLE QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0038U","CodeDescription":"VITAMIN D SERUM MICROSAMPLE QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0039U","CodeDescription":"DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0039U","CodeDescription":"DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0039U","CodeDescription":"DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0039U","CodeDescription":"DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0039U","CodeDescription":"DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00400","CodeDescription":"ANES INTEG EXTREMITIES ANT TRUNK & PERINEUM NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00402","CodeDescription":"ANESTHESIA RECONSTRUCTION BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00404","CodeDescription":"ANESTHESIA RADICAL\/MODIFIED RADICAL BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00406","CodeDescription":"ANES RADICAL\/MODIFIED RADICAL BREAST W\/NODES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0040U","CodeDescription":"BCR\/ABL1 GENE TLCJ ALYS MAJOR BP QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00410","CodeDescription":"ANES INTEG SYS ELEC CONVERSION ARRHYTHMIAS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0041U","CodeDescription":"B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0041U","CodeDescription":"B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0041U","CodeDescription":"B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0041U","CodeDescription":"B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0041U","CodeDescription":"B BURGDORFERI ANTB 5 PRTN GRP IMMUNOBLOT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0042U","CodeDescription":"B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0042U","CodeDescription":"B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0042U","CodeDescription":"B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0042U","CodeDescription":"B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0042U","CodeDescription":"B BURGDORFERI ANTB 12 PRTN GRP IMMUNOBLOT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0043U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0043U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0043U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0043U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0043U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0044U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0044U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0044U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0044U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0044U","CodeDescription":"TBRF B GRP ANTB DETCJ 4 RECOMB PRTN IMUNOBLT IGG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00450","CodeDescription":"ANESTHESIA CLAVICLE AND SCAPULA NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00454","CodeDescription":"ANESTHESIA CLAVICLE & SCAPULA BIOPSY CLAVICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0046U","CodeDescription":"FLT3 GENE INT TANDEM DUPL VARIANTS QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00470","CodeDescription":"ANESTHESIA PARTIAL RIB RESECTION NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00472","CodeDescription":"ANESTHESIA PARTIAL RIB RESECTION THORACOPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00474","CodeDescription":"ANESTHESIA PARTIAL RIB RESECTION RADICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0047U","CodeDescription":"ONC PRST8 MRNA GEN XPRS PRFL 17 GEN ALG RSK SCOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0049U","CodeDescription":"NPM1 GENE ANALYSIS QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00500","CodeDescription":"ANESTHESIA ESOPHAGUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0050U","CodeDescription":"TRGT GEN SEQ ALYS AML 194 GENE INTERROG SEQ VRNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0051U","CodeDescription":"RX MNTR DRUGS PRESENT LC-MS\/MS UR\/BLD 31 RX PNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0051U","CodeDescription":"RX MNTR DRUGS PRESENT LC-MS\/MS UR\/BLD 31 RX PNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0051U","CodeDescription":"RX MNTR DRUGS PRESENT LC-MS\/MS UR\/BLD 31 RX PNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0051U","CodeDescription":"RX MNTR DRUGS PRESENT LC-MS\/MS UR\/BLD 31 RX PNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0051U","CodeDescription":"RX MNTR DRUGS PRESENT LC-MS\/MS UR\/BLD 31 RX PNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00520","CodeDescription":"ANESTHESIA CLOSED CHEST W\/BRONCHOSCOPY NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00522","CodeDescription":"ANESTHESIA CLOSED CHEST NEEDLE BIOPSY PLEURA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00524","CodeDescription":"ANESTHESIA CLOSED CHEST PNEUMOCENTESIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00528","CodeDescription":"ANES MEDIASTINOSCOPY&THORACSCOPY W\/O 1 LUNG VNTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00529","CodeDescription":"ANES MEDIASTINOSCOPY&THORACOSCOPY W\/1 LUNG VNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0052U","CodeDescription":"LPOPRTN BLD W\/5 MAJ CLASS AUTO PRFL UCENTRFUGTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0052U","CodeDescription":"LPOPRTN BLD W\/5 MAJ CLASS AUTO PRFL UCENTRFUGTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0052U","CodeDescription":"LPOPRTN BLD W\/5 MAJ CLASS AUTO PRFL UCENTRFUGTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0052U","CodeDescription":"LPOPRTN BLD W\/5 MAJ CLASS AUTO PRFL UCENTRFUGTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0052U","CodeDescription":"LPOPRTN BLD W\/5 MAJ CLASS AUTO PRFL UCENTRFUGTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00530","CodeDescription":"ANES PERMANENT TRANSVENOUS PACEMAKER INSERTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00532","CodeDescription":"ANESTHESIA ACCESS CENTRAL VENOUS CIRCULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00534","CodeDescription":"ANES TRANSVENOUS INSJ\/REPLACEMENT PACING CVDFB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00537","CodeDescription":"ANES CARDIAC ELECTROPHYSIOL STDY W\/RF ABLATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00539","CodeDescription":"ANESTHESIA TRACHEOBRONCHIAL RECONSTRUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00540","CodeDescription":"ANES THORACOTOMY & THORACOSCOPY NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00541","CodeDescription":"ANES THORACOTOMY & THORACOSCOPY W\/1 LUNG VNTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00542","CodeDescription":"ANES THORACOTOMY & THORACOSCOPY DECORTICATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00546","CodeDescription":"ANES THORACOTOMY & THORACOSCOPY PULMONARY RESC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00548","CodeDescription":"ANES THORACOTOMY &THORACSCOPY TRACHEA & BRONCHI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0054U","CodeDescription":"RX MNTR 14+ CLASS DRUGS & SBSTS CAPILLARY BLOOD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0054U","CodeDescription":"RX MNTR 14+ CLASS DRUGS & SBSTS CAPILLARY BLOOD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0054U","CodeDescription":"RX MNTR 14+ CLASS DRUGS & SBSTS CAPILLARY BLOOD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0054U","CodeDescription":"RX MNTR 14+ CLASS DRUGS & SBSTS CAPILLARY BLOOD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0054U","CodeDescription":"RX MNTR 14+ CLASS DRUGS & SBSTS CAPILLARY BLOOD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00550","CodeDescription":"ANESTHESIA FOR STERNAL DEBRIDEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00560","CodeDescription":"ANES HRT PERICARDIAL SAC& GRT VESLS W\/O PMP OXT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00561","CodeDescription":"ANES HRT PERICARD SAC&GREAT VSLS W\/PMP OXTJ  LT 1YR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00562","CodeDescription":"ANES HRT PERICRD SAC&GRT VSLS W\/PMP OXTJ GT 1MO PO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00563","CodeDescription":"ANES HRT PRCRD SAC & GREAT VSL W\/PUMP OXTJ HYPTH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00566","CodeDescription":"ANES DIRECT CABG W\/O PUMP OXYGENATOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00567","CodeDescription":"ANES DIRECT CABG W\/PUMP OXYGENATOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00580","CodeDescription":"ANES HEART TRANSPLANT\/HEART\/LUNG TRANSPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0058U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0058U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0058U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0058U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0058U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM QUAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0059U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM REPRTD +\/-","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0059U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM REPRTD +\/-","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0059U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM REPRTD +\/-","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0059U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM REPRTD +\/-","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0059U","CodeDescription":"ONC MERKEL CELL CARC DETCJ ANTB SERUM REPRTD +\/-","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00600","CodeDescription":"ANESTHESIA CERVICAL SPINE & CORD NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00604","CodeDescription":"ANES CERVICAL SPINE & CORD W\/PATIENT SITTING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00620","CodeDescription":"ANESTHESIA THORACIC SPINE & CORD NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00625","CodeDescription":"ANES THRC SPINE & CORD ANT APPR W\/O 1 LUNG VENTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00626","CodeDescription":"ANES THORACIC SPINE & CORD ANT APPR W\/1 LNG VENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00630","CodeDescription":"ANESTHESIA LUMBAR REGION NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00632","CodeDescription":"ANESTHESIA LUMBAR REGION LUMBAR SYMPATHECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00635","CodeDescription":"ANES DIAGNOSTIC\/THERAPEUTIC LUMBAR PUNCTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00640","CodeDescription":"ANES MANIPULATE SPINE\/CLSD CRV THORC\/LUMBR SPINE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0064U","CodeDescription":"ANTIBODY TREPONEMA PALLIDUM TOTAL & RPR IA QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0065U","CodeDescription":"SYPHILIS TST NON-TREPONEMAL ANTIBODY IA QUAL RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00670","CodeDescription":"ANESTHESIA EXTENSIVE SPINE & SPINAL CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0068U","CodeDescription":"CANDIDA SPECIES PANEL AMP PRB TQ W\/QUAL REPORT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0068U","CodeDescription":"CANDIDA SPECIES PANEL AMP PRB TQ W\/QUAL REPORT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0068U","CodeDescription":"CANDIDA SPECIES PANEL AMP PRB TQ W\/QUAL REPORT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0068U","CodeDescription":"CANDIDA SPECIES PANEL AMP PRB TQ W\/QUAL REPORT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0068U","CodeDescription":"CANDIDA SPECIES PANEL AMP PRB TQ W\/QUAL REPORT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00700","CodeDescription":"ANESTHESIA UPPER ANTERIOR ABDOMINAL WALL NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00702","CodeDescription":"ANES UPR ANT ABDL WALL PERCUTANEOUS LIVER BX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00730","CodeDescription":"ANESTHESIA UPPER POSTERIOR ABDOMINAL WALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00731","CodeDescription":"ANESTHESIA UPPER GI ENDOSCOPIC PX NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00732","CodeDescription":"ANESTHESIA UPPER GI ENDOSCOPIC PX ERCP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00750","CodeDescription":"ANESTHESIA HERNIA REPAIR UPPER ABDOMEN NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00752","CodeDescription":"ANES HRNA RPR UPR ABD LMBR&VENTRAL HERNIA&DEHISC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00754","CodeDescription":"ANES HERNIA REPAIR UPPER ABDOMEN OMPHALOCELE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00756","CodeDescription":"ANES HRNA REPAIR UPR ABD TABDL RPR DIPHRG HRNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00770","CodeDescription":"ANESTHESIA MAJOR ABDOMINAL BLOOD VESSELS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0077U","CodeDescription":"IG PARAPROTEIN QUAL IMPRCIP&MS BLD\/UR W\/ISOTYPE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0077U","CodeDescription":"IG PARAPROTEIN QUAL IMPRCIP&MS BLD\/UR W\/ISOTYPE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0077U","CodeDescription":"IG PARAPROTEIN QUAL IMPRCIP&MS BLD\/UR W\/ISOTYPE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0077U","CodeDescription":"IG PARAPROTEIN QUAL IMPRCIP&MS BLD\/UR W\/ISOTYPE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0077U","CodeDescription":"IG PARAPROTEIN QUAL IMPRCIP&MS BLD\/UR W\/ISOTYPE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00790","CodeDescription":"ANES INTRAPERITONEAL UPPER ABDOMEN W\/LAPS NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00792","CodeDescription":"ANES LAPS PARTIAL HEPATECTOMY W\/MGMT LIVER HEMOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00794","CodeDescription":"ANES LAPAROSCOPIC PARTIAL\/TOTAL PANCREATECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00796","CodeDescription":"ANES LAPAROSCOPIC LIVER TRANSPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00797","CodeDescription":"ANES IPR UPPER ABDOMEN LAPS GASTRIC RSTCV MO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00800","CodeDescription":"ANESTHESIA LOWER ANTERIOR ABDOMINAL WALL NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00802","CodeDescription":"ANES LOWER ANT ABDOMINAL WALL PANNICULECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00811","CodeDescription":"ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00812","CodeDescription":"ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00813","CodeDescription":"ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00820","CodeDescription":"ANESTHESIA LOWER POSTERIOR ABDOMINAL WALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0082U","CodeDescription":"RX TST DEF 90+ RX\/SBSTS UR REPRT PRES\/ABS EA RX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0082U","CodeDescription":"RX TST DEF 90+ RX\/SBSTS UR REPRT PRES\/ABS EA RX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0082U","CodeDescription":"RX TST DEF 90+ RX\/SBSTS UR REPRT PRES\/ABS EA RX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0082U","CodeDescription":"RX TST DEF 90+ RX\/SBSTS UR REPRT PRES\/ABS EA RX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0082U","CodeDescription":"RX TST DEF 90+ RX\/SBSTS UR REPRT PRES\/ABS EA RX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"00830","CodeDescription":"ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00832","CodeDescription":"ANES LWR ABD VENTRAL & INCISIONAL HERNIA REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00834","CodeDescription":"ANES HERNIA REPAIR LOWER ABDOMEN NOS & 1YR AGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00836","CodeDescription":"ANES HRNA RPR LWR ABD NOS INFTS  LT 37WK BRTH\/50WK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00840","CodeDescription":"ANESTHESIA INTRAPERITONEAL LOWER ABD W\/LAPS NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00842","CodeDescription":"ANES IPER LOWER ABDOMEN W\/LAPS AMNIOCENTESIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00844","CodeDescription":"ANES IPER LOWER ABD W\/LAPS ABDOMINOPRNL RESCJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00846","CodeDescription":"ANES IPER LOWER ABD W\/LAPS RAD HYSTERECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00848","CodeDescription":"ANES IPER LOWER ABD W\/LAPS PELVIC EXENTERATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0084U","CodeDescription":"RBC DNA GNOTYP 10 BLD GRP PHNT PREDICT 37 RBC AG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00851","CodeDescription":"ANES IPER LWR ABD W\/LAPS TUBAL LIGATION\/TRANSECT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00860","CodeDescription":"ANES EXTRAPERITONEAL LWR ABD W\/URINARY TRACT NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00862","CodeDescription":"ANES XTRPRTL LOWER ABD UR TRACT RENAL DON NFRCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00864","CodeDescription":"ANES XTRPRTL LWER ABD W\/URINARY TRACT TOT CYSTEC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00865","CodeDescription":"ANES XTRPRTL LWR ABD W\/URINARY TRACT RAD PRSTECT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00866","CodeDescription":"ANES XTRPRTL LOWER ABD W\/URIN TRACT ADRENLECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00868","CodeDescription":"ANES XTRPRTL LWR ABD W\/URIN TRACT RENAL TRANSPL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00870","CodeDescription":"ANES XTRPRTL LWR ABD W\/URIN TRACT CSTOLITHOTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00872","CodeDescription":"ANES LITHOTRP XTRCORP SHOCK WAVE W\/WATER BATH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00873","CodeDescription":"ANES LITHOTRP XTRCORP SHOCK WAVE W\/O WATER BATH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0087U","CodeDescription":"CARD HRT TRNSPL MRNA GEN XPRS PRFL 1283 GENE ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00880","CodeDescription":"ANESTHESIA MAJOR LOWER ABDOMINAL VESSELS NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00882","CodeDescription":"ANES MAJOR LOWER ABDOMINAL VESSELS IVC LIGATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0088U","CodeDescription":"TRNSPLJ MED KDN ALGRFT REJ 1494 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"00902","CodeDescription":"ANESTHESIA ANORECTAL PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00904","CodeDescription":"ANESTHESIA RADICAL PERINEAL PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00906","CodeDescription":"ANESTHESIA VULVECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00908","CodeDescription":"ANESTHESIA PERINEAL PROSTATECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00910","CodeDescription":"ANES TRANSURETHRAL W\/URETHROCYSTOSCOPY NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00912","CodeDescription":"ANES TRANSURETHRAL RESECTION OF BLADDER TUMOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00914","CodeDescription":"ANESTHESIA TRANSURETHRAL RESECTION OF PROSTATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00916","CodeDescription":"ANES TRURL POST-TRURL RESECTION BLEEDING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00918","CodeDescription":"ANES TRURL FRAGMNTJ MANJ&\/RMVL URETERAL CALCULUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00920","CodeDescription":"ANESTHESIA MALE GENITALIA INCL OPEN URETHRAL PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00922","CodeDescription":"ANES SEMINAL VESICLES INCL OPEN URETHRAL PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00924","CodeDescription":"ANES UNDSCND TESTIS UNI\/BI INCL OPEN URTL PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00926","CodeDescription":"ANES RAD ORCHIECTOMY INGUN INCL OPEN URTL PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00928","CodeDescription":"ANES RAD ORCHIECTOMY ABDOMINAL INCL OPN URTL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00930","CodeDescription":"ANES ORCHIOPEXY UNI\/BI INCL OPEN URETHRAL PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00932","CodeDescription":"ANES COMPLETE AMPUTATION PENIS INCL OPEN URTL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00934","CodeDescription":"ANES RAD AMP PENIS W\/BI INGUINAL LYMPH NODE RMVL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00936","CodeDescription":"ANES RAD AMP PENIS W\/BI INGUNL&ILIAC LYMPH RMOVL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00938","CodeDescription":"ANES INSJ PENILE PROSTH PRNL INCL OPEN URTL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00940","CodeDescription":"ANESTHESIA VAGINAL PROCEDURE W\/BIOPSY NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00942","CodeDescription":"ANES COLPTMY VAGNC COLPRPHY INCL BX W\/OPN URTL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00944","CodeDescription":"ANESTHESIA VAGINAL HYSTERECTOMY INCL BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00948","CodeDescription":"ANESTHESIA CERVICAL CERCLAGE INCLUDING BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00950","CodeDescription":"ANESTHESIA CULDOSCOPY INCLUDING BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"00952","CodeDescription":"ANES HYSTEROSCOPY&\/HYSTEROSALPINGOGRAPHY W\/BX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0107U","CodeDescription":"C DIFF TOXIN ANTIGEN DETCJ IA TECH STOOL QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0107U","CodeDescription":"C DIFF TOXIN ANTIGEN DETCJ IA TECH STOOL QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0107U","CodeDescription":"C DIFF TOXIN ANTIGEN DETCJ IA TECH STOOL QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0107U","CodeDescription":"C DIFF TOXIN ANTIGEN DETCJ IA TECH STOOL QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0107U","CodeDescription":"C DIFF TOXIN ANTIGEN DETCJ IA TECH STOOL QUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0109U","CodeDescription":"ID ASPERGILLUS DNA 4 SPECIES BLD LVG FLU\/TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0109U","CodeDescription":"ID ASPERGILLUS DNA 4 SPECIES BLD LVG FLU\/TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0109U","CodeDescription":"ID ASPERGILLUS DNA 4 SPECIES BLD LVG FLU\/TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0109U","CodeDescription":"ID ASPERGILLUS DNA 4 SPECIES BLD LVG FLU\/TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0109U","CodeDescription":"ID ASPERGILLUS DNA 4 SPECIES BLD LVG FLU\/TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"01112","CodeDescription":"ANES BONE MARROW ASPIR&\/BX ANT\/PST ILIAC CREST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01120","CodeDescription":"ANESTHESIA ON BONY PELVIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01130","CodeDescription":"ANESTHESIA BODY CAST APPLICATION OR REVISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01140","CodeDescription":"ANESTHESIA INTERPELVI ABDOMINAL AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01150","CodeDescription":"ANES RADICAL TUMOR PELVIS XCP HINDQUARTER AMP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01160","CodeDescription":"ANES CLOSED SYMPHYSIS PUBIS\/SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01170","CodeDescription":"ANES OPEN SYMPHYSIS PUBIS\/SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01173","CodeDescription":"ANES OPN RPR DISRPJ PELVIS\/COLUMN FX ACETABULUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01200","CodeDescription":"ANESTHESIA CLOSED HIP JOINT PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01202","CodeDescription":"ANESTHESIA ARTHROSCOPIC HIP JOINT PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0120U","CodeDescription":"ONC B CLL LYMPHM MRNA GENE XPRSN PRFL 58 GEN ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01210","CodeDescription":"ANESTHESIA OPEN HIP JOINT PROCEDURE NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01212","CodeDescription":"ANESTHESIA OPEN HIP JOINT DISARTICULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01214","CodeDescription":"ANESTHESIA OPEN TOTAL HIP ARTHROPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01215","CodeDescription":"ANESTHESIA OPEN REVISION TOTAL HIP ARTHROPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01220","CodeDescription":"ANESTHESIA CLOSED PROCEDURES UPPER 2\/3 FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01230","CodeDescription":"ANESTHESIA OPEN PROCEDURES UPPER 2\/3 FEMUR NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01232","CodeDescription":"ANESTHESIA UPPER 2\/3 FEMUR AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01234","CodeDescription":"ANES UPPER 2\/3 FEMUR RADICAL RESCECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01250","CodeDescription":"ANES NERVE MUSC TENDON FASCIA & BURSAE UPPER LEG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01260","CodeDescription":"ANES VEINS OF UPPER LEG INCLUDING EXPLORATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01270","CodeDescription":"ANESTHESIA ARTERIES UPPER LEG INCL BYPASS GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01272","CodeDescription":"ANES ART UPPER LEG W\/BYPASS GRAFT FEM ART LIG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01274","CodeDescription":"ANES UPPER LEG W\/BYPASS GRFT FEM ART EMBOLECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01320","CodeDescription":"ANES NERVE MUSC TENDON FASCIA&BURSA KNEE&\/POPLT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01340","CodeDescription":"ANESTHESIA CLOSED PROCEDURES LOWER 1\/3 FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01360","CodeDescription":"ANESTHESIA OPEN PROCEDURES LOWER 1\/3 FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01380","CodeDescription":"ANESTHESIA CLOSED PROCEDURES KNEE JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01382","CodeDescription":"ANESTH DIAGNOSTIC ARTHROSCOPIC PROC KNEE JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01390","CodeDescription":"ANES CLOSED PROC UPPER END TIBIA FIBULA\/PATELLA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01392","CodeDescription":"ANES OPEN PROC UPPER ENDS TIBIA FIBULA&\/PATELLA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01400","CodeDescription":"ANES OPEN\/SURG ARTHROSCOPIC PROC KNEE JOINT NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01402","CodeDescription":"ANESTH OPEN\/SURG ARTHRS TOTAL KNEE ARTHROPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01404","CodeDescription":"ANESTH OPEN\/SURG ARTHRS KNEE DISARTICULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0140U","CodeDescription":"NFCT DS FUNGAL PATHOGEN ID DNA 15 FUNGAL TARGETS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0140U","CodeDescription":"NFCT DS FUNGAL PATHOGEN ID DNA 15 FUNGAL TARGETS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0140U","CodeDescription":"NFCT DS FUNGAL PATHOGEN ID DNA 15 FUNGAL TARGETS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0140U","CodeDescription":"NFCT DS FUNGAL PATHOGEN ID DNA 15 FUNGAL TARGETS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0140U","CodeDescription":"NFCT DS FUNGAL PATHOGEN ID DNA 15 FUNGAL TARGETS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0141U","CodeDescription":"NFCT DS BACT&FNG GRAM POS ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0141U","CodeDescription":"NFCT DS BACT&FNG GRAM POS ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0141U","CodeDescription":"NFCT DS BACT&FNG GRAM POS ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0141U","CodeDescription":"NFCT DS BACT&FNG GRAM POS ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0141U","CodeDescription":"NFCT DS BACT&FNG GRAM POS ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"01420","CodeDescription":"ANES CAST APPLICATION REMOVAL\/REPAIR KNEE JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0142U","CodeDescription":"NFCT DS BACT&FNG GRAM NEG ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0142U","CodeDescription":"NFCT DS BACT&FNG GRAM NEG ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0142U","CodeDescription":"NFCT DS BACT&FNG GRAM NEG ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0142U","CodeDescription":"NFCT DS BACT&FNG GRAM NEG ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0142U","CodeDescription":"NFCT DS BACT&FNG GRAM NEG ORG ID & RX RESIST DNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"01430","CodeDescription":"ANESTHESIA VEINS KNEE & POPLITEAL AREA NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01432","CodeDescription":"ANES KNEE & POPLITEAL ARTERY VEIN FISTULA NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01440","CodeDescription":"ANES ARTERIES OF KNEE & POPLITEAL AREA NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01442","CodeDescription":"ANES ART KNEE POPLITEAL TEAEC W\/WO PATCH GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01444","CodeDescription":"ANES ART KNEE POPLITEAL EXC&GRF\/RPR OCCLS\/ARYS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01462","CodeDescription":"ANESTHESIA CLOSED PROC LOWER LEG ANKLE & FOOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01464","CodeDescription":"ANESTHESIA ARTHROSCOPIC PROCEDURE ANKLE & FOOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01470","CodeDescription":"ANES NRV\/MUS\/TND\/FASC LOWER LEG\/ANKLE\/FOOT NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01472","CodeDescription":"ANES RPR RUPTURED ACHILLES TENDON W\/WO GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01474","CodeDescription":"ANESTHESIA GASTROCNEMIUS RECESSION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01480","CodeDescription":"ANES OPEN PROC BONES LOWER LEG\/ANKLE\/FOOT NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01482","CodeDescription":"ANES RADICAL RESECJ INCL BELOW KNEE AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01484","CodeDescription":"ANES OPEN OSTEOTOMY\/OSTEOPLASTY TIBIA&\/FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01486","CodeDescription":"ANESTHESIA OPEN TOTAL ANKLE REPLACEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01490","CodeDescription":"ANES LOWER LEG CAST APPLICATION REMOVAL\/REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01500","CodeDescription":"ANESTHESIA ARTERIES LOWER LEG W\/BYPASS GRAFT NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01502","CodeDescription":"ANES ART LOWER LEG W\/BYP GRAFT EMBLC DIR\/W\/CATH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01520","CodeDescription":"ANESTHESIA VEINS OF LOWER LEG NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01522","CodeDescription":"ANES VEINS LOWER LEG VENOUS THRMBC DIR\/W\/CATH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0154U","CodeDescription":"ONC UROTHELIAL CANCER RNA RT-PCR FGFR3 GENE ALYS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0155U","CodeDescription":"ONC BRST CA DNA PIK3CA GENE ALYS BRST TUM TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0157U","CodeDescription":"APC GENE MRNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0158U","CodeDescription":"MLH1 GENE MRNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0159U","CodeDescription":"MSH2 GENE MRNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0160U","CodeDescription":"MSH6 GENE MRNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01610","CodeDescription":"ANES NRV MUSC TNDN FSCIA BURSA SHOULDER & AXILLA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0161U","CodeDescription":"PMS2 GENE MRNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01620","CodeDescription":"ANES CLOSED HUMRL H\/N STRNCLAV JOINT& SHO JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01622","CodeDescription":"ANES DIAG ARTHROSCOPIC SHOULDER JOINT PROC NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0162U","CodeDescription":"HERED COLON CA TARGETED MRNA SEQUENCE ALYS PANEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01630","CodeDescription":"ANES ARTHRS HUMERAL H\/N STRNCLAV & SHOULDER NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01634","CodeDescription":"ANESTHESIA ARTHROSCOPIC SHOULDER DISARTICULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01636","CodeDescription":"ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01638","CodeDescription":"ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01650","CodeDescription":"ANESTHESIA ARTERIES SHOULDER & AXILLA NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01652","CodeDescription":"ANESTHESIA AXILLARY-BRACHIAL ANEURYSM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01654","CodeDescription":"ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01656","CodeDescription":"ANESTHESIA AXILLARY-FEMORAL BYPASS GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0165U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD PROB ALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0165U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD PROB ALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0165U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD PROB ALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0165U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD PROB ALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0165U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD PROB ALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0166U","CodeDescription":"LIVER DISEASE 10 BIOCHEMICAL ASSAYS SERUM ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0166U","CodeDescription":"LIVER DISEASE 10 BIOCHEMICAL ASSAYS SERUM ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0166U","CodeDescription":"LIVER DISEASE 10 BIOCHEMICAL ASSAYS SERUM ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0166U","CodeDescription":"LIVER DISEASE 10 BIOCHEMICAL ASSAYS SERUM ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0166U","CodeDescription":"LIVER DISEASE 10 BIOCHEMICAL ASSAYS SERUM ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"01670","CodeDescription":"ANESTHESIA VEINS SHOULDER & AXILLA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0167U","CodeDescription":"CHORIONIC GONADOTROPIN HCG IA DIR OPT OBS BLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0167U","CodeDescription":"CHORIONIC GONADOTROPIN HCG IA DIR OPT OBS BLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0167U","CodeDescription":"CHORIONIC GONADOTROPIN HCG IA DIR OPT OBS BLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0167U","CodeDescription":"CHORIONIC GONADOTROPIN HCG IA DIR OPT OBS BLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0167U","CodeDescription":"CHORIONIC GONADOTROPIN HCG IA DIR OPT OBS BLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"01680","CodeDescription":"ANES SHOULDER CAST APPL REMOVAL\/REPAIR NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0169U","CodeDescription":"NUDT15 & TPMT GENE ANALYSIS COMMON VARIANTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01710","CodeDescription":"ANES NRV MUSC TDN FSCA&BRS UPR ARM\/ELBOW NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01712","CodeDescription":"ANESTHESIA OPEN TENOTOMY ELBOW TO SHOULDER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01714","CodeDescription":"ANESTHESIA TENOPLASTY ELBOW TO SHOULDER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01716","CodeDescription":"ANESTHESIA BICEPS TENODESIS RUPTURE LONG TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0171U","CodeDescription":"TARGETED GENOMIC SEQUENCE ALYS PNL DNA 23 GENES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0172U","CodeDescription":"ONC SLD TUM SOMATIC MUT ALYS BRCA1 BRCA2 ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01730","CodeDescription":"ANESTHESIA CLOSED PROCEDURES HUMERUS & ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01732","CodeDescription":"ANESTHESIA ELBOW JOINT DIAGNOSTIC ARTHROSCOPIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01740","CodeDescription":"ANES OPEN\/SURG ARTHROSCOPIC ELBOW PROC NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01742","CodeDescription":"ANESTHESIA OPEN\/SURG ARTHRS OSTEOTOMY HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01744","CodeDescription":"ANES OPEN\/SURG ARTHRS REPRS NON\/MALUNION HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01756","CodeDescription":"ANESTHESIA OPEN\/SURG ARTHRS RADICAL PROC ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01758","CodeDescription":"ANESTH OPEN\/SURG ARTHRS EXC CYST\/TUMOR HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01760","CodeDescription":"ANESTH OPEN\/SURG ARTHRS TOTAL ELBOW REPLACEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01770","CodeDescription":"ANESTHESIA ARTERIES UPPER ARM & ELBOW NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01772","CodeDescription":"ANESTHESIA ARTERIES UPPER ARM&ELBOW EMBOLECTOM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0177U","CodeDescription":"ONC BRST CA DNA PIK3CA GEN ALYS 11 GEN VRNT PLSM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01780","CodeDescription":"ANESTHESIA VEINS UPPER ARM & ELBOW NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01782","CodeDescription":"ANESTHESIA VEINS UPPER ARM & ELBOW PHLEBORRHAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0178U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD CLIN RXN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0178U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD CLIN RXN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0178U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD CLIN RXN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0178U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD CLIN RXN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0178U","CodeDescription":"PEANUT ALLG SPEC ASMT MLT EPI ELISA BLD CLIN RXN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0180U","CodeDescription":"ABO GNOTYP ALYS SANGER\/CHAIN SEQ ABO 7 EXONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01810","CodeDescription":"ANES NERVE MUSCLE TDN FASCIA&BURSA FOREARM WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0181U","CodeDescription":"CO GNOTYP GENE ANALYSIS AQP1 EXON 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01820","CodeDescription":"ANES RADIUS ULNA WRIST\/HAND BONES CLOSED PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01829","CodeDescription":"ANESTHESIA DIAGNOSTIC ARTHROSCOPIC PROC WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0182U","CodeDescription":"CROM GNOTYP GENE ANALYSIS CD55 EXONS 1-10","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01830","CodeDescription":"ANES ARTHRS\/ENDSCPY DSTL RADIUS ULNA\/WRIST\/HAND","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01832","CodeDescription":"ANESTHESIA ARTHRS\/ENDOSCPIC TOTAL WRIST REPLCMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0183U","CodeDescription":"DI GNOTYP GENE ANALYSIS SLC4A1 EXON 19","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01840","CodeDescription":"ANESTHESIA ARTERIES FOREARM WRIST & HAND NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01842","CodeDescription":"ANES ARTERIES FOREARM WRIST & HAND EMBOLECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01844","CodeDescription":"ANESTHESIA VASCULAR SHUNT\/SHUNT REVISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0184U","CodeDescription":"DO GNOTYP GENE ANALYSIS ART4 EXON 2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01850","CodeDescription":"ANESTHESIA VEINS FOREARM WRIST & HAND NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01852","CodeDescription":"ANES VEINS FOREARM WRIST & HAND PHLEBORRHAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0185U","CodeDescription":"FUT1 GNOTYP GENE ANALYSIS FUT1 EXON 4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01860","CodeDescription":"ANES FOREARM WRIST\/HAND CAST APPL RMVL\/REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0186U","CodeDescription":"FUT2 GNOTYP GENE ANALYSIS FUT2 EXON 2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0187U","CodeDescription":"FY GNOTYP GENE ANALYSIS ACKR1 EXONS 1-2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0188U","CodeDescription":"GE GNOTYP GENE ANALYSIS GYPC EXONS 1-4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0189U","CodeDescription":"GYPA GNOTYP GENE ALYS GYPA INTRONS 1 5 EXON 2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0190U","CodeDescription":"GYPB GNOTYP ALYS GYPB INTRON 1 5 PSEUDOEXON 3","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01916","CodeDescription":"ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY\/VENOGRAPH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0191U","CodeDescription":"IN GNOTYP GENE ANALYSIS CD44 EXONS 2 3 6","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01920","CodeDescription":"ANES C-CATHJ W\/C ANGIOGRAPHY & VENTRICULOGRAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01922","CodeDescription":"ANES NON-INVASIVE IMAGING\/RADIATION THERAPY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01924","CodeDescription":"ANESTHESIA THER IVNTL RADIOLOGICAL ARTERIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01925","CodeDescription":"ANESTHESIA CAROTID\/CORONARY THER IVNTL RAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01926","CodeDescription":"ANES ICRA ICAR\/AORTIC THER IVNTL RAD ARTL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0192U","CodeDescription":"JK GNOTYP GENE ANALYSIS SLC14A1 GEN PRMTR EXON 9","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01930","CodeDescription":"ANES VENOUS\/LYMPHATIC NOS THER IVNTL RAD NOS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01931","CodeDescription":"ANESTHESIA INTRAHEPATIC\/PORTAL THER IVNTL RAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01932","CodeDescription":"ANESTHESIA INTRATHORACIC\/JUGULAR THER IVNTL RAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01933","CodeDescription":"ANES INTRACRANIAL THER IVNTL RAD VENS\/LYMPHTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01937","CodeDescription":"ANES PERQ IMG NJX DRG\/ASPIR PX SPI\/SP CRV\/THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01938","CodeDescription":"ANES PERQ IMG NJX DRG\/ASPIR PX SPI\/SP LMBR\/SAC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01939","CodeDescription":"ANES PERQ IMG DSTRJ PX NULYT AGT SPI\/SP CRV\/THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0193U","CodeDescription":"JR GNOTYP GENE ANALYSIS ABCG2 EXONS 2-26","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01940","CodeDescription":"ANES PERQ IMG DSTRJ PX NULYT AGT SPI\/SP LMBR\/SAC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01941","CodeDescription":"ANES PERQ IMG NEUROMD\/NTRVRT PX SPI\/SP CRV\/THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01942","CodeDescription":"ANES PERQ IMG NEUROMD\/NTRVRT PX SPI\/SP LMBR\/SAC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0194U","CodeDescription":"KEL GNOTYP GENE ANALYSIS KEL EXON 8","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01951","CodeDescription":"ANES 2\/3 DGR BRN EXC\/DBRDMT W\/WO GRFT 4 % TBSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01952","CodeDescription":"ANES 2\/3 DGR BRN EXC\/DBRDMT W\/WO GRFT 4-9 % TBSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01953","CodeDescription":"ANES 2\/3 DGR BRN EXC\/DBRDMT W\/WO GRF EA 9% TBS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01958","CodeDescription":"ANESTHESIA EXTERNAL CEPHALIC VERSION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0195U","CodeDescription":"KLF1 TARGETED SEQUENCING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01960","CodeDescription":"ANESTHESIA VAGINAL DELIVERY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01961","CodeDescription":"ANESTHESIA CESAREAN DELIVERY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01962","CodeDescription":"ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01963","CodeDescription":"ANESTHESIA C HYST W\/O ANY LABOR ANALG\/ANES CARE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01967","CodeDescription":"NEURAXIAL LABOR ANALG\/ANES PLND VAGINAL DELIVERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01968","CodeDescription":"ANES CESARN DLVR FLWG NEURAXIAL LABOR ANALG\/ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01969","CodeDescription":"ANES CESARN HYST FLWG NEURAXIAL LABOR ANALG\/ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0196U","CodeDescription":"LU GNOTYP GENE ANALYSIS BCAM EXON 3","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0197U","CodeDescription":"LW GNOTYP GENE ANALYSIS ICAM4 EXON 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0198U","CodeDescription":"RHD&RHCE GNOTYP SANGER\/CHAIN SEQ RHD 1-10&RHCE 5","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"01990","CodeDescription":"PHYSIOL SUPPORT HARVEST ORGAN FROM BRAIN-DEAD PT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01991","CodeDescription":"ANES DX\/THER NRV BLK\/NJX OTH\/THN PRONE POS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01992","CodeDescription":"ANES DX\/THER NERVE BLOCK\/INJECTION PRONE POS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01996","CodeDescription":"DAILY HOSP MGMT EDRL\/SARACH CONT DRUG ADMN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01999","CodeDescription":"UNLISTED ANESTHESIA PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0199U","CodeDescription":"SC GNOTYP GENE ANALYSIS ERMAP EXONS 4 12","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0200U","CodeDescription":"XK GNOTYP GENE ANALYSIS XK EXONS 1-3","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0202U","CodeDescription":"NFCT DS BCT\/VIR RESPIR DNA\/RNA 22 TRGT SARSCOV2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0204U","CodeDescription":"ONC THYR MRNA GENE XPRSN ALYS 593 GENES FNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0210U","CodeDescription":"SYPHILIS TST NON-TREPONEMAL ANTIBODY IA QUAN RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0216U","CodeDescription":"NEURO INH ATAXIA GENOMIC DNA SEQ ALYS 12 BLD\/SLV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0217U","CodeDescription":"NEURO INH ATAXIA GENOMIC DNA SEQ ALYS 51 BLD\/SLV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0218U","CodeDescription":"NEURO MUSCULAR DYSTROPHY DMD SEQ ALYS BLD\/SALIVA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0219U","CodeDescription":"NFCT AGENT HIV TRGT VIRAL NEXT-GNRJ SEQ ALYS ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0221U","CodeDescription":"ABO GNOTYP GENE ALYS NEXT-GENERATION SEQ ABO GEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0222U","CodeDescription":"RHD&RHCE GNOTYP NEXT-GNRJ SEQ RH PROX PROMOTER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0223U","CodeDescription":"NFCT DS BCT\/VIR RESPIR DNA\/RNA 22 TRGT SARSCOV2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0224U","CodeDescription":"ANTB SEV AQT RESPIR SYND CORONAVIRUS 2 TITER(S)","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0225U","CodeDescription":"NFCT DS DNA&RNA 21 TARGETS SARS-COV-2 AMP PROBE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0226U","CodeDescription":"SUROGAT VIR NEUTRLZJ TST SARSCOV2 ELISA PLSM SRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0227U","CodeDescription":"RX ASSAY PRSMV 30+RX\/METABLT UR LC-MS\/MS MRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0227U","CodeDescription":"RX ASSAY PRSMV 30+RX\/METABLT UR LC-MS\/MS MRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0227U","CodeDescription":"RX ASSAY PRSMV 30+RX\/METABLT UR LC-MS\/MS MRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0227U","CodeDescription":"RX ASSAY PRSMV 30+RX\/METABLT UR LC-MS\/MS MRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0227U","CodeDescription":"RX ASSAY PRSMV 30+RX\/METABLT UR LC-MS\/MS MRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0230U","CodeDescription":"AR FUL SEQ ALYS CHNG DELET DUPL XPNSJ INSJ VRNTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0231U","CodeDescription":"CACNA1A FUL GEN ALY CHNG DELT DUP XPNSJ INSJ VRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0232U","CodeDescription":"CSTB FUL GEN ALY CHNG DELET DUPL XPNSJ INSJ VRNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0233U","CodeDescription":"FXN GENE ALYS CHNG DELET DUPL XPNSJ INSJ VRNTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0234U","CodeDescription":"MECP2 FUL GEN ALYS CHANGES DELET DUPL INSJ VRNTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0235U","CodeDescription":"PTEN FULL GEN ALYS CHANGES DELET DUPL INSJ VRNTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0236U","CodeDescription":"SMN1&SMN2 FUL GEN ALYS CHNG DUPL&DELET&INSJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0237U","CodeDescription":"CARDIAC ION CHANNELOPATHIES GENOMIC SEQ ALYS PNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0238U","CodeDescription":"ONC LYNCH SYNDROME GENOMIC DNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0239U","CodeDescription":"TRGT GEN SEQ ALYS SLD ORGN NEO CLL-FR DNA 311+","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0240U","CodeDescription":"NFCT DS RNA 3 TARGETS UPPER RESPIRATORY SPECIMEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0241U","CodeDescription":"NFCT DS RNA 4 TARGETS UPPER RESPIRATORY SPECIMEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0242U","CodeDescription":"TRGT GEN SEQ ALYS PNL SOLID ORGN NEO DNA 55-74","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0244U","CodeDescription":"ONC SOLID ORGN DNA COMPRE GENOMIC PRFLG 257 GENE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0245U","CodeDescription":"ONC THYR MUT ALYS 10 GEN 37 RNA FSN XPRSN 4 MRNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0246U","CodeDescription":"RBC DNA GNOTYP 16 BLD GRP PHNT PREDICT 51 RBC AG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0268U","CodeDescription":"HEM ATYP HEMOLYTIC UREMC SYND GEN SEQ ALY 15 GEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0271U","CodeDescription":"HEM CGEN NEUTROPENIA GEN SEQ ALYS 23 GENES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0275U","CodeDescription":"HEM HEPARIN INDUCD TRMBCTPNA PLTLT ANTB REAC SRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0275U","CodeDescription":"HEM HEPARIN INDUCD TRMBCTPNA PLTLT ANTB REAC SRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0275U","CodeDescription":"HEM HEPARIN INDUCD TRMBCTPNA PLTLT ANTB REAC SRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0275U","CodeDescription":"HEM HEPARIN INDUCD TRMBCTPNA PLTLT ANTB REAC SRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0275U","CodeDescription":"HEM HEPARIN INDUCD TRMBCTPNA PLTLT ANTB REAC SRM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0276U","CodeDescription":"HEM INH THROMBOCYTOPENIA GEN SEQ ALYS 42 GENES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0279U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0279U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0279U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0279U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0279U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN III BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0280U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN IV BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0280U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN IV BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0280U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN IV BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0280U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN IV BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0280U","CodeDescription":"HEM VW DS VW FACTOR & COLLAGEN IV BINDING ELISA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0281U","CodeDescription":"HEM VW DS VW PROPEPTIDE ELISA AG LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0281U","CodeDescription":"HEM VW DS VW PROPEPTIDE ELISA AG LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0281U","CodeDescription":"HEM VW DS VW PROPEPTIDE ELISA AG LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0281U","CodeDescription":"HEM VW DS VW PROPEPTIDE ELISA AG LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0281U","CodeDescription":"HEM VW DS VW PROPEPTIDE ELISA AG LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0282U","CodeDescription":"RBC DNA GNOTYP 12 BLD GRP PREDICT 44 RBC AG PHNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0282U","CodeDescription":"RBC DNA GNOTYP 12 BLD GRP PREDICT 44 RBC AG PHNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0282U","CodeDescription":"RBC DNA GNOTYP 12 BLD GRP PREDICT 44 RBC AG PHNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0282U","CodeDescription":"RBC DNA GNOTYP 12 BLD GRP PREDICT 44 RBC AG PHNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0282U","CodeDescription":"RBC DNA GNOTYP 12 BLD GRP PREDICT 44 RBC AG PHNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0283U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2B PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0283U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2B PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0283U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2B PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0283U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2B PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0283U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2B PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0284U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0284U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0284U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0284U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0284U","CodeDescription":"VON WILLEBRAND FACTOR TYPE 2N FACTOR VIII PLASMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0286U","CodeDescription":"CEP72 NUDT15&TPMT GENE ANALYSIS COMMON VARIANTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0287U","CodeDescription":"ONC THYR DNA&MRNA NEXT-GEN SEQ ALYS 112 GEN ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0301U","CodeDescription":"IADNA BARTONELLA HENSELAE & QUINTANA DDPCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0301U","CodeDescription":"IADNA BARTONELLA HENSELAE & QUINTANA DDPCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0301U","CodeDescription":"IADNA BARTONELLA HENSELAE & QUINTANA DDPCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0301U","CodeDescription":"IADNA BARTONELLA HENSELAE & QUINTANA DDPCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0301U","CodeDescription":"IADNA BARTONELLA HENSELAE & QUINTANA DDPCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0302U","CodeDescription":"IADNA BRTNLA HNSLAE&QUINTN DDPCR FLWG LIQ NRCHMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0302U","CodeDescription":"IADNA BRTNLA HNSLAE&QUINTN DDPCR FLWG LIQ NRCHMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0302U","CodeDescription":"IADNA BRTNLA HNSLAE&QUINTN DDPCR FLWG LIQ NRCHMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0302U","CodeDescription":"IADNA BRTNLA HNSLAE&QUINTN DDPCR FLWG LIQ NRCHMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0302U","CodeDescription":"IADNA BRTNLA HNSLAE&QUINTN DDPCR FLWG LIQ NRCHMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0311U","CodeDescription":"NFCT DS BCT QUAN ANTMCRB SC MIC EA ORG ID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0311U","CodeDescription":"NFCT DS BCT QUAN ANTMCRB SC MIC EA ORG ID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0311U","CodeDescription":"NFCT DS BCT QUAN ANTMCRB SC MIC EA ORG ID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0311U","CodeDescription":"NFCT DS BCT QUAN ANTMCRB SC MIC EA ORG ID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0311U","CodeDescription":"NFCT DS BCT QUAN ANTMCRB SC MIC EA ORG ID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0312U","CodeDescription":"AI DS SLE ALYS 8 IGG AUTOANT&2 CLL BOUND PRDCTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0312U","CodeDescription":"AI DS SLE ALYS 8 IGG AUTOANT&2 CLL BOUND PRDCTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0312U","CodeDescription":"AI DS SLE ALYS 8 IGG AUTOANT&2 CLL BOUND PRDCTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0312U","CodeDescription":"AI DS SLE ALYS 8 IGG AUTOANT&2 CLL BOUND PRDCTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0312U","CodeDescription":"AI DS SLE ALYS 8 IGG AUTOANT&2 CLL BOUND PRDCTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0314U","CodeDescription":"ONC CUTAN MLNMA MRNA GEN XPRSN PRFL 35 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0314U","CodeDescription":"ONC CUTAN MLNMA MRNA GEN XPRSN PRFL 35 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0314U","CodeDescription":"ONC CUTAN MLNMA MRNA GEN XPRSN PRFL 35 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0314U","CodeDescription":"ONC CUTAN MLNMA MRNA GEN XPRSN PRFL 35 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0314U","CodeDescription":"ONC CUTAN MLNMA MRNA GEN XPRSN PRFL 35 GENES ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0321U","CodeDescription":"IADNA GU PTHGN 20BCT&FNGL ORG&ID 16 ABX RSIST GN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0321U","CodeDescription":"IADNA GU PTHGN 20BCT&FNGL ORG&ID 16 ABX RSIST GN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0321U","CodeDescription":"IADNA GU PTHGN 20BCT&FNGL ORG&ID 16 ABX RSIST GN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0321U","CodeDescription":"IADNA GU PTHGN 20BCT&FNGL ORG&ID 16 ABX RSIST GN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0321U","CodeDescription":"IADNA GU PTHGN 20BCT&FNGL ORG&ID 16 ABX RSIST GN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0323U","CodeDescription":"IADNA CNS PATHOGEN NEXT-GENERATION SEQUENCING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0323U","CodeDescription":"IADNA CNS PATHOGEN NEXT-GENERATION SEQUENCING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0323U","CodeDescription":"IADNA CNS PATHOGEN NEXT-GENERATION SEQUENCING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0323U","CodeDescription":"IADNA CNS PATHOGEN NEXT-GENERATION SEQUENCING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0323U","CodeDescription":"IADNA CNS PATHOGEN NEXT-GENERATION SEQUENCING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0324U","CodeDescription":"ONC OVAR SPHRD CLL CUL 4 RX PNL TUM CHEMO RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0324U","CodeDescription":"ONC OVAR SPHRD CLL CUL 4 RX PNL TUM CHEMO RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0324U","CodeDescription":"ONC OVAR SPHRD CLL CUL 4 RX PNL TUM CHEMO RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0324U","CodeDescription":"ONC OVAR SPHRD CLL CUL 4 RX PNL TUM CHEMO RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0324U","CodeDescription":"ONC OVAR SPHRD CLL CUL 4 RX PNL TUM CHEMO RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0325U","CodeDescription":"ONC OVAR SPHRD CLL CUL PARP INHIBITOR TUM RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0325U","CodeDescription":"ONC OVAR SPHRD CLL CUL PARP INHIBITOR TUM RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0325U","CodeDescription":"ONC OVAR SPHRD CLL CUL PARP INHIBITOR TUM RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0325U","CodeDescription":"ONC OVAR SPHRD CLL CUL PARP INHIBITOR TUM RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0325U","CodeDescription":"ONC OVAR SPHRD CLL CUL PARP INHIBITOR TUM RSPSE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0326U","CodeDescription":"TRGT GEN SEQ ALYS SLD ORGN NEO CLL-FR DNA 83+","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0327U","CodeDescription":"FTL ANEUPLOIDY TRSMY DNA SEQ ALYS MAT PLSM RSK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0328U","CodeDescription":"DRUG ASSAY DEF 120+ RX&METABOLITES UR W\/LC-MS\/MS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0329U","CodeDescription":"ONC NEOPLASIA XOME&TRNS SEQ ALYS DNA&RNA TUMOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0330U","CodeDescription":"IADNA VAG PTHGN PNL 27 ORG AMP PROBE VAG SWAB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0330U","CodeDescription":"IADNA VAG PTHGN PNL 27 ORG AMP PROBE VAG SWAB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0330U","CodeDescription":"IADNA VAG PTHGN PNL 27 ORG AMP PROBE VAG SWAB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0330U","CodeDescription":"IADNA VAG PTHGN PNL 27 ORG AMP PROBE VAG SWAB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0330U","CodeDescription":"IADNA VAG PTHGN PNL 27 ORG AMP PROBE VAG SWAB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0331U","CodeDescription":"ONC HL NEO OPT GEN MAPPING W\/DNA BLD\/BONE MARROW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0333U","CodeDescription":"ONC LVR SRVLNC HCC ALYS METHYLTN PATTERNS CFDNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0334U","CodeDescription":"ONC SLD ORGN TGSA FFPE TUM TISS DNA 84\/+ GEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0337U","CodeDescription":"ONC PLSM CLL DO&MYLOMA CRCG PLSM CLL IMMLG SLCTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0338U","CodeDescription":"ONC SLD TUM CRCG TUMOR CELL SELECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0339U","CodeDescription":"ONC PROSTATE MRNA XPRSN PRFLG HOXC6 &DLX1 RT-PCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0341U","CodeDescription":"FETAL ANEUPLOIDY DNA SEQUENCING COMPARATIVE ALYS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0342U","CodeDescription":"ONC PNCRTC CA MULT IA ECLIA SRM ALG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0343U","CodeDescription":"ONC PRST8 XOME BASED ALYS 442 SNCRNA RT-QPCR UR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0344U","CodeDescription":"HEP NAFLD SEMIQ EVAL 28 LIPID MRK SRM NASH\/XNASH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0344U","CodeDescription":"HEP NAFLD SEMIQ EVAL 28 LIPID MRK SRM NASH\/XNASH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0344U","CodeDescription":"HEP NAFLD SEMIQ EVAL 28 LIPID MRK SRM NASH\/XNASH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0344U","CodeDescription":"HEP NAFLD SEMIQ EVAL 28 LIPID MRK SRM NASH\/XNASH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0344U","CodeDescription":"HEP NAFLD SEMIQ EVAL 28 LIPID MRK SRM NASH\/XNASH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0353U","CodeDescription":"IADNA CHLMYD TRCHMTS&NEISSRA GONORR MULT AMP PRB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0354U","CodeDescription":"HPV HIGH RISK QUALITATIVE MRNA XPRSN E6\/E7 QPCR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0402T","CodeDescription":"COLLAGEN CROSS-LINKING CORNEA&PACHYMETRY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0402T","CodeDescription":"COLLAGEN CROSS-LINKING CORNEA&PACHYMETRY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0402T","CodeDescription":"COLLAGEN CROSS-LINKING CORNEA&PACHYMETRY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0402T","CodeDescription":"COLLAGEN CROSS-LINKING CORNEA&PACHYMETRY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0402T","CodeDescription":"COLLAGEN CROSS-LINKING CORNEA&PACHYMETRY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"0558T","CodeDescription":"CT SCAN FOR PURPOSE BIOMECHANICAL CT ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":10004,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10004,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10004,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10004,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10004,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10005,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10005,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10005,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10005,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10005,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10006,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10006,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10006,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10006,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10006,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/US GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10007,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10007,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10007,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10007,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10007,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10008,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10008,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10008,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10008,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10008,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/FLUOR GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10009,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10009,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10009,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10009,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10009,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10010,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10010,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10010,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10010,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10010,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/CT GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10011,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/MR GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10012,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/MR GDN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10021,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10021,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10021,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10021,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10021,"CodeDescription":"FINE NEEDLE ASPIRATION BX W\/O IMG GDN 1ST LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10030,"CodeDescription":"IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10030,"CodeDescription":"IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10030,"CodeDescription":"IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10030,"CodeDescription":"IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10030,"CodeDescription":"IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10035,"CodeDescription":"PERQ SFT TISS LOC DEVICE PLMT 1ST LES W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10036,"CodeDescription":"PERQ SFT TISS LOC DEVICE PLMT ADD LES W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10040,"CodeDescription":"ACNE SURGERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10060,"CodeDescription":"INCISION & DRAINAGE ABSCESS SIMPLE\/SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10060,"CodeDescription":"INCISION & DRAINAGE ABSCESS SIMPLE\/SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10060,"CodeDescription":"INCISION & DRAINAGE ABSCESS SIMPLE\/SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10060,"CodeDescription":"INCISION & DRAINAGE ABSCESS SIMPLE\/SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10060,"CodeDescription":"INCISION & DRAINAGE ABSCESS SIMPLE\/SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10061,"CodeDescription":"INCISION & DRAINAGE ABSCESS COMPLICATED\/MULTIPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10080,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10080,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10080,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10080,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10080,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10081,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST COMPLICATED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10120,"CodeDescription":"INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10120,"CodeDescription":"INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10120,"CodeDescription":"INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10120,"CodeDescription":"INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10120,"CodeDescription":"INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10121,"CodeDescription":"INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10140,"CodeDescription":"I&D HEMATOMA SEROMA\/FLUID COLLECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10140,"CodeDescription":"I&D HEMATOMA SEROMA\/FLUID COLLECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10140,"CodeDescription":"I&D HEMATOMA SEROMA\/FLUID COLLECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10140,"CodeDescription":"I&D HEMATOMA SEROMA\/FLUID COLLECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10140,"CodeDescription":"I&D HEMATOMA SEROMA\/FLUID COLLECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10160,"CodeDescription":"PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA\/CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10160,"CodeDescription":"PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA\/CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":10160,"CodeDescription":"PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA\/CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10160,"CodeDescription":"PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA\/CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10160,"CodeDescription":"PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA\/CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":10180,"CodeDescription":"INCISION & DRAINAGE COMPLEX PO WOUND INFECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11000,"CodeDescription":"DBRDMT EXTENSV ECZEMA\/INFECT SKN UP 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11000,"CodeDescription":"DBRDMT EXTENSV ECZEMA\/INFECT SKN UP 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11000,"CodeDescription":"DBRDMT EXTENSV ECZEMA\/INFECT SKN UP 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11000,"CodeDescription":"DBRDMT EXTENSV ECZEMA\/INFECT SKN UP 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11000,"CodeDescription":"DBRDMT EXTENSV ECZEMA\/INFECT SKN UP 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11001,"CodeDescription":"DBRDMT EXTNSVE ECZEMA\/INFECT SKN EA 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11001,"CodeDescription":"DBRDMT EXTNSVE ECZEMA\/INFECT SKN EA 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11001,"CodeDescription":"DBRDMT EXTNSVE ECZEMA\/INFECT SKN EA 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11001,"CodeDescription":"DBRDMT EXTNSVE ECZEMA\/INFECT SKN EA 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11001,"CodeDescription":"DBRDMT EXTNSVE ECZEMA\/INFECT SKN EA 10% BDY SURF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11004,"CodeDescription":"DBRDMT SKN SUBQ T\/M\/F NECRO INFCTJ GENT&PR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11005,"CodeDescription":"DBRDMT SKN SUBQ T\/M\/F NECRO INFCTJ ABDL WALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11006,"CodeDescription":"DBRDMT SKN SUBQ T\/M\/F NECRO INFCTJ GENT\/ABDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11008,"CodeDescription":"REMOVAL PROSTHETIC MATRL ABDL WALL FOR INFECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11010,"CodeDescription":"DBRDMT W\/RMVL FM FX&\/DISLC SKIN&SUBQ TISSUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11011,"CodeDescription":"DBRDMT W\/RMVL FM FX&\/DISLC SKN SUBQ T\/M\/F MUSC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11012,"CodeDescription":"DBRDMT FX&\/DISLC SUBQ T\/M\/F BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11042,"CodeDescription":"DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":11043,"CodeDescription":"DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":11044,"CodeDescription":"DEBRIDEMENT BONE MUSCLE &\/FASCIA 20 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11045,"CodeDescription":"DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11045,"CodeDescription":"DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11045,"CodeDescription":"DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11045,"CodeDescription":"DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11045,"CodeDescription":"DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11046,"CodeDescription":"DEBRIDEMENT MUSCLE &\/FASCIA EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11046,"CodeDescription":"DEBRIDEMENT MUSCLE &\/FASCIA EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11046,"CodeDescription":"DEBRIDEMENT MUSCLE &\/FASCIA EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11046,"CodeDescription":"DEBRIDEMENT MUSCLE &\/FASCIA EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11046,"CodeDescription":"DEBRIDEMENT MUSCLE &\/FASCIA EA ADDL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11047,"CodeDescription":"DEBRIDEMENT BONE EACH ADDITIONAL 20 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11055,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11055,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11055,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11055,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11055,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11056,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 2-4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11056,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 2-4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11056,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 2-4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11056,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 2-4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11056,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION 2-4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11057,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION GT 4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11057,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION GT 4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11057,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION GT 4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11057,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION GT 4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11057,"CodeDescription":"PARING\/CUTTING BENIGN HYPERKERATOTIC LESION GT 4","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11102,"CodeDescription":"TANGENTIAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11102,"CodeDescription":"TANGENTIAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11102,"CodeDescription":"TANGENTIAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11102,"CodeDescription":"TANGENTIAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11102,"CodeDescription":"TANGENTIAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11103,"CodeDescription":"TANGENTIAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11103,"CodeDescription":"TANGENTIAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11103,"CodeDescription":"TANGENTIAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11103,"CodeDescription":"TANGENTIAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11103,"CodeDescription":"TANGENTIAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11104,"CodeDescription":"PUNCH BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11104,"CodeDescription":"PUNCH BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11104,"CodeDescription":"PUNCH BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11104,"CodeDescription":"PUNCH BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11104,"CodeDescription":"PUNCH BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11105,"CodeDescription":"PUNCH BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11105,"CodeDescription":"PUNCH BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11105,"CodeDescription":"PUNCH BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11105,"CodeDescription":"PUNCH BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11105,"CodeDescription":"PUNCH BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11106,"CodeDescription":"INCISIONAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11106,"CodeDescription":"INCISIONAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11106,"CodeDescription":"INCISIONAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11106,"CodeDescription":"INCISIONAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11106,"CodeDescription":"INCISIONAL BIOPSY SKIN SINGLE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11107,"CodeDescription":"INCISIONAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11107,"CodeDescription":"INCISIONAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11107,"CodeDescription":"INCISIONAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11107,"CodeDescription":"INCISIONAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11107,"CodeDescription":"INCISIONAL BIOPSY SKIN EA SEP\/ADDITIONAL LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11200,"CodeDescription":"REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW\/15","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11201,"CodeDescription":"REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11300,"CodeDescription":"SHAVING SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11300,"CodeDescription":"SHAVING SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11300,"CodeDescription":"SHAVING SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11300,"CodeDescription":"SHAVING SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11300,"CodeDescription":"SHAVING SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11301,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11301,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11301,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL 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LESION 1 TRUNK\/ARM\/LEG DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11302,"CodeDescription":"SHVG SKN LESION 1 TRUNK\/ARM\/LEG DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11302,"CodeDescription":"SHVG SKN LESION 1 TRUNK\/ARM\/LEG DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11302,"CodeDescription":"SHVG SKN LESION 1 TRUNK\/ARM\/LEG DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11303,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11303,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11303,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11303,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11303,"CodeDescription":"SHVG SKIN LESION 1 TRUNK\/ARM\/LEG DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11305,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11305,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11305,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11305,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11305,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11306,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11306,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11306,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11306,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11306,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11307,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11307,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11307,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11307,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11307,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11308,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11308,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11308,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11308,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11308,"CodeDescription":"SHAVING SKIN LESION 1 S\/N\/H\/F\/G DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11310,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11310,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11310,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11310,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11310,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11311,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11311,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11311,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11311,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11311,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11312,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11312,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11312,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11312,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11312,"CodeDescription":"SHVG SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11313,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11313,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11313,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11313,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11313,"CodeDescription":"SHAVING SKIN LESION 1 F\/E\/E\/N\/L\/M DIAM GT 2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11400,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11400,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11400,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11400,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11400,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11401,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11401,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11401,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11401,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11401,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11402,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11402,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization 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Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11403,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11403,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11403,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11403,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11403,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11404,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11404,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11404,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11404,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11404,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11406,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11406,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11406,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11406,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11406,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11420,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL 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MRGN XCP SK TG S\/N\/H\/F\/G 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11421,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11421,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11421,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11421,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11421,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11422,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11422,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11422,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11422,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11422,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11423,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11423,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11423,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11423,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11423,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11424,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11424,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11424,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11424,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11424,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11426,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11426,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11426,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11426,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11426,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG S\/N\/H\/F\/G  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11440,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11440,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11440,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11440,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11440,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11441,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11441,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11441,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11441,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11441,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11442,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11442,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ 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2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11443,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11443,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11443,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11443,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11444,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11444,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11444,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11444,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11444,"CodeDescription":"EXC B9 LES MRGN XCP SK TG F\/E\/E\/N\/L\/M 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11446,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11446,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11446,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11446,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11446,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG F\/E\/E\/N\/L\/M  GT  4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11450,"CodeDescription":"EXCISION HIDRADENITIS AXILLARY SMPL\/INTRM RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11451,"CodeDescription":"EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11462,"CodeDescription":"EXCISION HIDRADENITIS INGUINAL SMPL\/INTRM RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11463,"CodeDescription":"EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11470,"CodeDescription":"EXCISION H\/P\/P\/U SIMPLE\/INTERMEDIATE REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11471,"CodeDescription":"EXCISION H\/P\/P\/U COMPLEX REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11600,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11601,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11602,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11603,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11604,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11606,"CodeDescription":"EXCISION MALIGNANT LESION TRUNK\/ARM\/LEG  GT  4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11620,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11621,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11622,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11623,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11624,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11626,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11640,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11641,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11642,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 1.1-2.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11643,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 2.1-3.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11644,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 3.1-4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11646,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11720,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 1-5","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11720,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 1-5","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11720,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 1-5","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11720,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 1-5","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11720,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 1-5","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11721,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 6 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11721,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 6 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11721,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 6 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11721,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 6 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11721,"CodeDescription":"DEBRIDEMENT NAIL ANY METHOD 6 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11730,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMPLETE SIMPLE 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11730,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMPLETE SIMPLE 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11730,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMPLETE SIMPLE 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11730,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMPLETE SIMPLE 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11730,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMPLETE SIMPLE 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11732,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMP SIMPLE EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11732,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMP SIMPLE EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11732,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMP SIMPLE EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11732,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMP SIMPLE EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11732,"CodeDescription":"AVULSION NAIL PLATE PARTIAL\/COMP SIMPLE EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11740,"CodeDescription":"EVACUATION SUBUNGUAL HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11740,"CodeDescription":"EVACUATION SUBUNGUAL HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11740,"CodeDescription":"EVACUATION SUBUNGUAL HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11740,"CodeDescription":"EVACUATION SUBUNGUAL HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11740,"CodeDescription":"EVACUATION SUBUNGUAL HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11750,"CodeDescription":"EXCISION NAIL MATRIX PERMANENT REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11750,"CodeDescription":"EXCISION NAIL MATRIX PERMANENT REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11750,"CodeDescription":"EXCISION NAIL MATRIX PERMANENT REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11750,"CodeDescription":"EXCISION NAIL MATRIX PERMANENT REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11750,"CodeDescription":"EXCISION NAIL MATRIX PERMANENT REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11755,"CodeDescription":"BIOPSY NAIL UNIT SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11755,"CodeDescription":"BIOPSY NAIL UNIT SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11755,"CodeDescription":"BIOPSY NAIL UNIT SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11755,"CodeDescription":"BIOPSY NAIL UNIT SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11755,"CodeDescription":"BIOPSY NAIL UNIT SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11760,"CodeDescription":"REPAIR NAIL BED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11762,"CodeDescription":"RECONSTRUCTION NAIL BED W\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11765,"CodeDescription":"WEDGE EXCISION SKIN NAIL FOLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11765,"CodeDescription":"WEDGE EXCISION SKIN NAIL FOLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11765,"CodeDescription":"WEDGE EXCISION SKIN NAIL FOLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11765,"CodeDescription":"WEDGE EXCISION SKIN NAIL FOLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11765,"CodeDescription":"WEDGE EXCISION SKIN NAIL FOLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11770,"CodeDescription":"EXCISION PILONIDAL CYST\/SINUS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11771,"CodeDescription":"EXCISION PILONIDAL CYST\/SINUS EXTENSIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11772,"CodeDescription":"EXCISION PILONIDAL CYST\/SINUS COMPLICATED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11900,"CodeDescription":"INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11900,"CodeDescription":"INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11900,"CodeDescription":"INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11900,"CodeDescription":"INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11900,"CodeDescription":"INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11901,"CodeDescription":"INJECTION INTRALESIONAL GT 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11901,"CodeDescription":"INJECTION INTRALESIONAL GT 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11901,"CodeDescription":"INJECTION INTRALESIONAL GT 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11901,"CodeDescription":"INJECTION INTRALESIONAL GT 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11901,"CodeDescription":"INJECTION INTRALESIONAL GT 7 LESIONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11960,"CodeDescription":"INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11970,"CodeDescription":"REPLACEMENT TISSUE EXPANDER W\/PERMANENT IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11971,"CodeDescription":"REMOVAL TISSUE EXPANDER W\/O INSERTION IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11980,"CodeDescription":"SUBCUTANEOUS HORMONE PELLET IMPLANTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11982,"CodeDescription":"REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11983,"CodeDescription":"RMVL W\/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":12001,"CodeDescription":"SIMPLE REPAIR SCALP\/NECK\/AX\/GENIT\/TRUNK 2.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12002,"CodeDescription":"SMPL REPAIR SCALP\/NECK\/AX\/GENIT\/TRUNK 2.6-7.5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12004,"CodeDescription":"SIMPLE RPR SCALP\/NECK\/AX\/GENIT\/TRUNK 7.6-12.5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12005,"CodeDescription":"SMPL RPR SCALP\/NECK\/AX\/GENIT\/TRUNK 12.6-20.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12006,"CodeDescription":"SMPL RPR SCALP\/NECK\/AX\/GENIT\/TRUNK 20.1-30.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12007,"CodeDescription":"SIMPLE REPAIR SCALP\/NECK\/AX\/GENIT\/TRUNK GT 30.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12011,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M 2.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12013,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M 2.6CM-5.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12014,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M 5.1CM-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12015,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M 7.6CM-12.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12016,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M 12.6CM-20.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12017,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M 20.1CM-30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12018,"CodeDescription":"SIMPLE REPAIR F\/E\/E\/N\/L\/M GT 30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12020,"CodeDescription":"TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12021,"CodeDescription":"TX SUPERFICIAL WOUND DEHISCENCE W\/PACKING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12031,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12031,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12031,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12031,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12031,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12032,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12032,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12032,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12032,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12032,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12034,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 7.6-12.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12034,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 7.6-12.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12034,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 7.6-12.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12034,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 7.6-12.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12034,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 7.6-12.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12035,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 12.6-20.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12035,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 12.6-20.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12035,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 12.6-20.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12035,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 12.6-20.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12035,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 12.6-20.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12036,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 20.1-30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12036,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 20.1-30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12036,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 20.1-30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12036,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 20.1-30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12036,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E 20.1-30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12037,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E GT 30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12037,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E GT 30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12037,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E GT 30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12037,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E GT 30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12037,"CodeDescription":"REPAIR INTERMEDIATE S\/A\/T\/E GT 30.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12041,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 2.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical 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(NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13101,"CodeDescription":"REPAIR COMPLEX TRUNK 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13101,"CodeDescription":"REPAIR COMPLEX TRUNK 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13101,"CodeDescription":"REPAIR COMPLEX TRUNK 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13101,"CodeDescription":"REPAIR COMPLEX TRUNK 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13102,"CodeDescription":"REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13102,"CodeDescription":"REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13102,"CodeDescription":"REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13102,"CodeDescription":"REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13102,"CodeDescription":"REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13120,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13120,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13120,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13120,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13120,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13121,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13121,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13121,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13121,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13121,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13122,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13122,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13122,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13122,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13122,"CodeDescription":"REPAIR COMPLEX SCALP\/ARM\/LEG EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13131,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13131,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13131,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13131,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13131,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13132,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13132,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13132,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13132,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13132,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13133,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13133,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13133,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13133,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13133,"CodeDescription":"REPAIR COMPLEX F\/C\/C\/M\/N\/AX\/G\/H\/F EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13151,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13151,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13151,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13151,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13151,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 1.1-2.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13152,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13152,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13152,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13152,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13152,"CodeDescription":"REPAIR COMPLEX EYELID\/NOSE\/EAR\/LIP 2.6-7.5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13153,"CodeDescription":"REPAIR COMPLX EYELID\/NOSE\/EAR\/LIP EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13153,"CodeDescription":"REPAIR COMPLX EYELID\/NOSE\/EAR\/LIP EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":13153,"CodeDescription":"REPAIR COMPLX EYELID\/NOSE\/EAR\/LIP EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13153,"CodeDescription":"REPAIR COMPLX EYELID\/NOSE\/EAR\/LIP EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13153,"CodeDescription":"REPAIR COMPLX EYELID\/NOSE\/EAR\/LIP EA ADDL 5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":13160,"CodeDescription":"SECONDARY CLOSURE SURG WOUND\/DEHSN EXTSV\/COMPLIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14000,"CodeDescription":"ADJACENT TISSUE TRANSFER\/REARGMT TRUNK 10 SQCM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14001,"CodeDescription":"ADJNT TIS TRANSFR\/REARRANGE TRUNK 10.1-30.0 SQCM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14020,"CodeDescription":"ADJT TIS TRNSFR\/REARGMT SCALP\/ARM\/LEG 10 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14021,"CodeDescription":"ADJT\/REARRGMT SCALP\/ARM\/LEG 10.1-30.0 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14040,"CodeDescription":"ADJT TIS TRNS\/REARGMT F\/C\/C\/M\/N\/A\/G\/H\/F 10SQCM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14041,"CodeDescription":"ADJT\/REARGMT F\/C\/C\/M\/N\/AX\/G\/H\/F 10.1-30.0 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14060,"CodeDescription":"ADJT TIS TRNSFR\/REARRGMT E\/N\/E\/L DFCT 10 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14061,"CodeDescription":"ADJT TIS REARGMT EYE\/NOSE\/EAR\/LIP 10.1-30.0 SQCM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14301,"CodeDescription":"ADJNT TIS TRNSFR\/REARGMT ANY AREA 30.1-60 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14302,"CodeDescription":"ADJT TIS TRNSFR\/REARGMT DEFEC EA ADDL 30 SQCM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":14350,"CodeDescription":"FILLETED FINGER\/TOE FLAP W\/PREPJ RECIPIENT SITE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1494F","CodeDescription":"COGNITION ASSESSED AND REVIEWED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1494F","CodeDescription":"COGNITION ASSESSED AND REVIEWED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1494F","CodeDescription":"COGNITION ASSESSED AND REVIEWED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"1494F","CodeDescription":"COGNITION ASSESSED AND REVIEWED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":"1494F","CodeDescription":"COGNITION ASSESSED AND REVIEWED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15002,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15002,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15002,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15002,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15002,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15003,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15003,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15003,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15003,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15003,"CodeDescription":"PREP SITE TRUNK\/ARM\/LEG ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15004,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15004,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15004,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15004,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15004,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15005,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15005,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15005,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15005,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15005,"CodeDescription":"PREP SITE F\/S\/N\/H\/F\/G\/M\/D GT ADDL 100 SQ CM\/1PCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15040,"CodeDescription":"HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15050,"CodeDescription":"PINCH GRAFT 1\/MLT SM ULCER TIP\/OTH AREA 2CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15100,"CodeDescription":"SPLIT AGRFT T\/A\/L 1ST 100 CM\/&\/1% BDY INFT\/CHLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15101,"CodeDescription":"SPLIT AGRFT T\/A\/L EA 100 CM\/EA 1% BDY INFT\/CHLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15110,"CodeDescription":"EPIDRM AGRFT T\/A\/L 1ST 100 CM\/&\/1% BDY INFT\/CHLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15111,"CodeDescription":"EPIDRM AGRFT T\/A\/L EA 100 CM\/EA 1% BDY INFT\/CHLD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15115,"CodeDescription":"EPIDERMAL AGRFT F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15116,"CodeDescription":"EPIDERMAL AGRFT F\/S\/N\/H\/F\/G\/M\/D GT EA 100 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15120,"CodeDescription":"SPLIT AGRFT F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100 CM LE \/1 %","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15121,"CodeDescription":"SPLIT AGRFT F\/S\/N\/H\/F\/G\/M\/D GT EA 100 CM\/EA 1 %","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15130,"CodeDescription":"DERMAL AUTOGRAFT TRUNK\/ARM\/LEG 1ST 100 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15131,"CodeDescription":"DERMAL AUTOGRAFT TRUNK\/ARM\/LEG EA 100 CM\/EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15135,"CodeDescription":"DERMAL AUTOGRAFT F\/S\/N\/H\/F\/G\/M\/D GT 1ST 100","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15136,"CodeDescription":"DERMAL AGRFT F\/S\/N\/H\/F\/G\/M\/D GT EA 100 CM\/EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15150,"CodeDescription":"CLTR SKIN AUTOGRAFT T\/A\/L 1ST 25 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15151,"CodeDescription":"CLTR SKIN AGRFT T\/A\/L ADDL 1 CM-75 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15152,"CodeDescription":"CLTR SKIN AGRFT T\/A\/L EA 100 CM\/EA 1%BODY AREA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15155,"CodeDescription":"CLTR SKIN AGRFT F\/S\/N\/H\/F\/G\/M\/D GT 1ST 25CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15156,"CodeDescription":"CLTR SKIN AGRFT F\/S\/N\/H\/F\/G\/M\/D GT ADDL 1-75CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15157,"CodeDescription":"CLTR SKIN AGRFT F\/S\/N\/H\/F\/G\/M\/D GT EA 100 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15200,"CodeDescription":"FTH\/GFT FREE W\/DIRECT CLOSURE TRUNK 20 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15201,"CodeDescription":"FTH\/GFT FR W\/DIR CLSR TRNK EA ADDL 20 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15220,"CodeDescription":"FTH\/GFT FREE W\/DIRECT CLOSURE S\/A\/L 20 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15221,"CodeDescription":"FTH\/GFT FR W\/DIR CLSR S\/A\/L EA ADDL 20 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15240,"CodeDescription":"FTH\/GFT FR W\/DIR CLSR F\/C\/C\/M\/N\/AX\/G\/H\/F 20 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15241,"CodeDescription":"FTH\/GT FR W\/DIR CLSR F\/C\/C\/M\/N\/AX\/G\/H\/F EA20CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15260,"CodeDescription":"FTH\/GFT FREE W\/DIRECT CLOSURE N\/E\/E\/L 20 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15261,"CodeDescription":"FTH\/GFT FREE W\/DIR CLSR N\/E\/E\/L EA 20 SQ CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15271,"CodeDescription":"APP SKN SUB GRFT T\/A\/L AREA\/100SQ CM  LE 1ST 25","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15272,"CodeDescription":"APP SKN SUB GRFT T\/A\/L AREA\/100SQ CM EA ADL 25SC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15273,"CodeDescription":"APP SKN SUBGRFT T\/A\/L AREA\/100SQ CM 1ST 100SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15274,"CodeDescription":"APP SKN SUB GRFT T\/A\/L AREA GE 100SCM ADL 100SQCM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15275,"CodeDescription":"SUB GRFT F\/S\/N\/H\/F\/G\/M\/D  LT 100SQ CM 1ST 25 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15276,"CodeDescription":"SUB GRFT F\/S\/N\/H\/F\/G\/M\/D LT 100SQ CM EA ADDL25SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15277,"CodeDescription":"SUB GRFT F\/S\/N\/H\/F\/G\/M\/D GE 100SCM 1ST 100SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15278,"CodeDescription":"SUB GRFT F\/S\/N\/H\/F\/G\/M\/D GE 100SCM ADL 100SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15570,"CodeDescription":"FRMJ DIRECT\/TUBED PEDICLE W\/WO TRANSFER TRUNK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15572,"CodeDescription":"FRMJ DIRECT\/TUBE PEDICLE W\/WO TR SCALP ARMS\/LEGS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15574,"CodeDescription":"FRMJ DIR\/TUBE PEDCL W\/WOTR FH\/CH\/CH\/M\/N\/AX\/G\/H\/F","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15576,"CodeDescription":"FRMJ DIRECT\/TUBED PEDICLE W\/WOTR E\/N\/E\/L\/NTRORAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15600,"CodeDescription":"DELAY FLAP\/SECTIONING FLAP TRUNK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15610,"CodeDescription":"DELAY FLAP\/SECTIONING FLAP SCALP ARMS\/LEGS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15620,"CodeDescription":"DELAY FLAP\/SECTIONING FLAP F\/C\/C\/N\/AX\/G\/H\/F","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15630,"CodeDescription":"DELAY FLAP\/SCTJ FLAP EYELIDS NOSE EARS\/LIPS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15650,"CodeDescription":"TRANSFER ANY PEDICLE FLAP ANY LOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15730,"CodeDescription":"MIDFACE FLAP W\/PRESERVATION OF VASCULAR PEDICLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15731,"CodeDescription":"FOREHEAD FLAP W\/PRESERVATION VASCULAR PEDICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15733,"CodeDescription":"MUSC MYOQ\/FSCQ FLAP HEAD&NECK W\/NAMED VASC PEDCL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15734,"CodeDescription":"MUSC MYOCUTANEOUS\/FASCIOCUTANEOUS FLAP TRUNK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15736,"CodeDescription":"MUSC MYOCUTANEOUS\/FASCIOCUTANEOUS FLAP UXTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15738,"CodeDescription":"MUSC MYOCUTANEOUS\/FASCIOCUTANEOUS FLAP LXTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15740,"CodeDescription":"FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15750,"CodeDescription":"FLAP NEUROVASCULAR PEDICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15756,"CodeDescription":"FREE MUSCLE\/MYOCUTANEOUS FLAP W\/MVASC ANAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15757,"CodeDescription":"FREE SKIN FLAP W\/MICROVASCULAR ANASTOMOSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15758,"CodeDescription":"FREE FASCIAL FLAP W\/MICROVASCULAR ANASTOMOSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15760,"CodeDescription":"GRAFT COMPOSITE W\/PRIMARY CLOSURE DONOR AREA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15769,"CodeDescription":"GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15770,"CodeDescription":"GRAFT DERMA-FAT-FASCIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15771,"CodeDescription":"GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15772,"CodeDescription":"GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15773,"CodeDescription":"GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15774,"CodeDescription":"GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15776,"CodeDescription":"PUNCH GRAFT HAIR TRANSPLANT GT 15 PUNCH GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15777,"CodeDescription":"IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15780,"CodeDescription":"DERMABRASION TOTAL FACE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15781,"CodeDescription":"DERMABRASION SEGMENTAL FACE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15782,"CodeDescription":"DERMABRASION REGIONAL OTHER THAN FACE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15783,"CodeDescription":"DERMABRASION SUPERFICIAL ANY SITE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15786,"CodeDescription":"ABRASION 1 LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15787,"CodeDescription":"ABRASION EACH ADDITIONAL 4 LESIONS OR LESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15788,"CodeDescription":"CHEMICAL PEEL FACIAL EPIDERMAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15789,"CodeDescription":"CHEMICAL PEEL FACIAL DERMAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15792,"CodeDescription":"CHEMICAL PEEL NONFACIAL EPIDERMAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15793,"CodeDescription":"CHEMICAL PEEL NONFACIAL DERMAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15820,"CodeDescription":"BLEPHAROPLASTY LOWER EYELID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15821,"CodeDescription":"BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15822,"CodeDescription":"BLEPHAROPLASTY UPPER EYELID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15823,"CodeDescription":"BLEPHAROPLASTY UPPER EYELID W\/EXCESSIVE SKIN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15840,"CodeDescription":"GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15841,"CodeDescription":"GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15842,"CodeDescription":"GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15845,"CodeDescription":"GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15851,"CodeDescription":"REMOVAL SUTURES\/STAPLES REQUIRING ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15851,"CodeDescription":"REMOVAL SUTURES\/STAPLES REQUIRING ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15851,"CodeDescription":"REMOVAL SUTURES\/STAPLES REQUIRING ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15851,"CodeDescription":"REMOVAL SUTURES\/STAPLES REQUIRING ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15851,"CodeDescription":"REMOVAL SUTURES\/STAPLES REQUIRING ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":15860,"CodeDescription":"IV INJECTION TEST VASCULAR FLOW FLAP\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15877,"CodeDescription":"SUCTION ASSISTED LIPECTOMY TRUNK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15920,"CodeDescription":"EXC COCCYGEAL PR ULC W\/COCCYGECTOMY W\/PRIM SUTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15922,"CodeDescription":"EXC COCCYGEAL PR ULC W\/COCCYGECTOMY W\/FLAP CLSR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15931,"CodeDescription":"EXCISION SACRAL PRESSURE ULCER W\/PRIMARY SUTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15933,"CodeDescription":"EXC SACRAL PRESSURE ULC W\/PRIM SUTR W\/OSTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15934,"CodeDescription":"EXCISION SACRAL PRESSURE ULCER W\/SKIN FLAP CLSR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15935,"CodeDescription":"EXC SACRAL PR ULCER W\/SKN FLAP CLSR W\/OSTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15936,"CodeDescription":"EXC SAC PR ULC PREPJ MUSC\/MYOQ FLAP\/SKN GRF CLSR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15937,"CodeDescription":"EXC SAC PR ULC PREPJ MUSC\/MYOQ FLAP\/SKN GRF OSTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15940,"CodeDescription":"EXC ISCHIAL PRESSURE ULCER W\/PRIMARY SUTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15941,"CodeDescription":"EXC ISCHIAL PR ULC W\/PRIM SUTR W\/OSTC ISCHIECT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15944,"CodeDescription":"EXC ISCHIAL PRESSURE ULCER W\/SKIN FLAP CLOSURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15945,"CodeDescription":"EXC ISCHIAL PR ULC W\/SKN FLAP CLSR W\/OSTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15946,"CodeDescription":"EXC ISCHIAL PR ULCER W\/OSTC MUSC\/MYOQ FLAP\/SKIN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15950,"CodeDescription":"EXC TROCHANTERIC PRESSURE ULCER W\/PRIMARY SUTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15951,"CodeDescription":"EXC TRCHNTRIC PR ULCER W\/PRIM SUTR W\/OSTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15952,"CodeDescription":"EXC TROCHANTERIC PR ULCER W\/SKIN FLAP CLOSURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15953,"CodeDescription":"EXC TRCHNTRIC PR ULC W\/SKN FLAP CLSR W\/OSTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15956,"CodeDescription":"EXC TROCHANTERIC PR ULCER MUSC\/MYOQ FLAP\/SKIN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15958,"CodeDescription":"EXC TRCHNTRIC PR ULC MUSC\/MYOQ FLAP\/SKIN W\/OSTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15999,"CodeDescription":"UNLISTED PROCEDURE EXCISION PRESSURE ULCER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16000,"CodeDescription":"INITIAL TX 1ST DEGREE BURN LOCAL TX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16000,"CodeDescription":"INITIAL TX 1ST DEGREE BURN LOCAL TX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16000,"CodeDescription":"INITIAL TX 1ST DEGREE BURN LOCAL TX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":16000,"CodeDescription":"INITIAL TX 1ST DEGREE BURN LOCAL TX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":16000,"CodeDescription":"INITIAL TX 1ST DEGREE BURN LOCAL TX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":16020,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ SMALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16020,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ SMALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16020,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ SMALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":16020,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ SMALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":16020,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ SMALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":16025,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ MEDIUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16030,"CodeDescription":"DRS&\/DBRDMT PRTL-THKNS BURNS 1ST\/SBSQ LARGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16035,"CodeDescription":"ESCHAROTOMY FIRST INCISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":16036,"CodeDescription":"ESCHAROTOMY EACH ADDITIONAL INCISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17000,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 1ST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17000,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 1ST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17000,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 1ST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17000,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 1ST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17000,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 1ST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17003,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 2-14 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17003,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 2-14 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17003,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 2-14 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17003,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 2-14 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17003,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 2-14 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17004,"CodeDescription":"DESTRUCTION PREMALIGNANT LESION 15 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17106,"CodeDescription":"DESTRUCTION CUTANEOUS VASC PROLIFERATIVE  LT 10CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17107,"CodeDescription":"DSTRJ CUTANEOUS VASCULAR LESIONS 10.0-50.0 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17108,"CodeDescription":"DSTRJ CUTANEOUS VASCULAR LESIONS GT 50.0 SQ CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17110,"CodeDescription":"DESTRUCTION BENIGN LESIONS UP TO 14","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17110,"CodeDescription":"DESTRUCTION BENIGN LESIONS UP TO 14","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17110,"CodeDescription":"DESTRUCTION BENIGN LESIONS UP TO 14","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17110,"CodeDescription":"DESTRUCTION BENIGN LESIONS UP TO 14","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17110,"CodeDescription":"DESTRUCTION BENIGN LESIONS UP TO 14","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17111,"CodeDescription":"DESTRUCTION BENIGN LESIONS 15 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17111,"CodeDescription":"DESTRUCTION BENIGN LESIONS 15 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17111,"CodeDescription":"DESTRUCTION BENIGN LESIONS 15 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17111,"CodeDescription":"DESTRUCTION BENIGN LESIONS 15 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17111,"CodeDescription":"DESTRUCTION BENIGN LESIONS 15 GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17250,"CodeDescription":"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17250,"CodeDescription":"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17250,"CodeDescription":"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17250,"CodeDescription":"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17250,"CodeDescription":"CHEMICAL CAUTERIZATION OF GRANULATION TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17260,"CodeDescription":"DESTRUCTION MALIGNANT LESION T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17260,"CodeDescription":"DESTRUCTION MALIGNANT LESION T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17260,"CodeDescription":"DESTRUCTION MALIGNANT LESION T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17260,"CodeDescription":"DESTRUCTION MALIGNANT LESION T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17260,"CodeDescription":"DESTRUCTION MALIGNANT LESION T\/A\/L 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17261,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17261,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17261,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17261,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17261,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 0.6-1.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17262,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17262,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17262,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17262,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17262,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17263,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17264,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17266,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG  GT  4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17270,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17270,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17270,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17270,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17270,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17271,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17271,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17271,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17271,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17271,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17272,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17273,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17274,"CodeDescription":"DESTRUCTION MALIGNANT LESION S\/N\/H\/F\/G 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17276,"CodeDescription":"DSTRJ MAL LESION S\/N\/H\/F\/G LESION DIAM  GT  4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17280,"CodeDescription":"DESTRUCTION MALIGNANT LESION F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17280,"CodeDescription":"DESTRUCTION MALIGNANT LESION F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17280,"CodeDescription":"DESTRUCTION MALIGNANT LESION F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17280,"CodeDescription":"DESTRUCTION MALIGNANT LESION F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17280,"CodeDescription":"DESTRUCTION MALIGNANT LESION F\/E\/E\/N\/L\/M 0.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":17281,"CodeDescription":"DESTRUCTION MAL LESION F\/E\/E\/N\/L\/M 0.6-1.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17282,"CodeDescription":"DESTRUCTION MAL LESION F\/E\/E\/N\/L\/M 1.1-2.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17283,"CodeDescription":"DESTRUCTION MAL LESION F\/E\/E\/N\/L\/M 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17284,"CodeDescription":"DESTRUCTION MAL LESION F\/E\/E\/N\/L\/M 3.1-4.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17286,"CodeDescription":"DESTRUCTION MAL LESION F\/E\/E\/N\/L\/M GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17311,"CodeDescription":"MOHS MICROGRAPHIC H\/N\/H\/F\/G 1ST STAGE 5 BLOCKS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17312,"CodeDescription":"MOHS MICROGRAPHIC H\/N\/H\/F\/G EACH ADDL STAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17313,"CodeDescription":"MOHS TRUNK\/ARM\/LEG 1ST STAGE 5 BLOCKS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17314,"CodeDescription":"MOHS TRUNK\/ARM\/LEG EA STAGE AFTER 1ST STAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17315,"CodeDescription":"MOHS TRUNK\/ARM\/LEG EA ADDL BLOCK ANY STAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17340,"CodeDescription":"CRYOTHERAPY CO2 SLUSH LIQUID N2 ACNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17360,"CodeDescription":"CHEMICAL EXFOLIATION ACNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17380,"CodeDescription":"ELECTROLYSIS EPILATION EACH 30 MINUTES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":17999,"CodeDescription":"UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19000,"CodeDescription":"PUNCTURE ASPIRATION CYST BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19000,"CodeDescription":"PUNCTURE ASPIRATION CYST BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19000,"CodeDescription":"PUNCTURE ASPIRATION CYST BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19000,"CodeDescription":"PUNCTURE ASPIRATION CYST BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19000,"CodeDescription":"PUNCTURE ASPIRATION CYST BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19001,"CodeDescription":"PUNCTURE ASPIRATION BREAST EACH ADDITIONAL CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19001,"CodeDescription":"PUNCTURE ASPIRATION BREAST EACH ADDITIONAL CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19001,"CodeDescription":"PUNCTURE ASPIRATION BREAST EACH ADDITIONAL CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19001,"CodeDescription":"PUNCTURE ASPIRATION BREAST EACH ADDITIONAL CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19001,"CodeDescription":"PUNCTURE ASPIRATION BREAST EACH ADDITIONAL CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19020,"CodeDescription":"MASTOTOMY W\/EXPLORATION\/DRAINAGE ABSCESS DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19030,"CodeDescription":"INJECTION MAMMARY DUCTOGRAM\/GALACTOGRAM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19081,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION STEREOTACTIC GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19081,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION STEREOTACTIC GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19081,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION STEREOTACTIC GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19081,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION STEREOTACTIC GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19081,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION STEREOTACTIC GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19082,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION STEREOTACT GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19082,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION STEREOTACT GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19082,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION STEREOTACT GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19082,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION STEREOTACT GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19082,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION STEREOTACT GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19083,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19083,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19083,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19083,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19083,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19084,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19084,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19084,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19084,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19084,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION ULTRASOUND GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19085,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION MAGNETIC RES GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19086,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION MAGNET RES GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19100,"CodeDescription":"BX BREAST NEEDLE CORE W\/O IMAGING GUIDANCE SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19101,"CodeDescription":"BIOPSY BREAST OPEN INCISIONAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19101,"CodeDescription":"BIOPSY BREAST OPEN INCISIONAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19101,"CodeDescription":"BIOPSY BREAST OPEN INCISIONAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19101,"CodeDescription":"BIOPSY BREAST OPEN INCISIONAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19101,"CodeDescription":"BIOPSY BREAST OPEN INCISIONAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19110,"CodeDescription":"NIPPLE EXPLORATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19112,"CodeDescription":"EXCISION LACTIFEROUS DUCT FISTULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19120,"CodeDescription":"EXC CYST\/ABERRANT BREAST TISSUE OPEN 1 GE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19120,"CodeDescription":"EXC CYST\/ABERRANT BREAST TISSUE OPEN 1 GE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19120,"CodeDescription":"EXC CYST\/ABERRANT BREAST TISSUE OPEN 1 GE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19120,"CodeDescription":"EXC CYST\/ABERRANT BREAST TISSUE OPEN 1 GE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19120,"CodeDescription":"EXC CYST\/ABERRANT BREAST TISSUE OPEN 1 GE LESION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19125,"CodeDescription":"EXC BREAST LES PREOP PLMT RAD MARKER OPEN 1 LES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19126,"CodeDescription":"EXC BRST LES PREOP PLMT RAD MARKER OPN EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19281,"CodeDescription":"PERQ DEVICE PLACEMENT BREAST LOC 1ST LES W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19282,"CodeDescription":"PERQ DEVICE PLACEMT BREAST LOC EA LESION W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19282,"CodeDescription":"PERQ DEVICE PLACEMT BREAST LOC EA LESION W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19282,"CodeDescription":"PERQ DEVICE PLACEMT BREAST LOC EA LESION W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19282,"CodeDescription":"PERQ DEVICE PLACEMT BREAST LOC EA LESION W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19282,"CodeDescription":"PERQ DEVICE PLACEMT BREAST LOC EA LESION W\/GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19283,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19284,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19284,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19284,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19284,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19284,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19285,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19286,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19286,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19286,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19286,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19286,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19287,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO MR GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19288,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19294,"CodeDescription":"PREP TUMOR CAVITY IORT W\/PARTIAL MASTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19296,"CodeDescription":"PLMT EXPANDABLE CATH BRST FOLLOWING PRTL MAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19297,"CodeDescription":"PLMT EXPANDABLE CATH BRST CONCURRENT PRTL MAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19298,"CodeDescription":"PLMT RADTHX BRACHYTX BRST FOLLOWING PRTL MAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19300,"CodeDescription":"MASTECTOMY GYNECOMASTIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19301,"CodeDescription":"MASTECTOMY PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19302,"CodeDescription":"MASTECTOMY PARTIAL W\/AXILLARY LYMPHADENECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19303,"CodeDescription":"MASTECTOMY SIMPLE COMPLETE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19305,"CodeDescription":"MAST RAD W\/PECTORAL MUSCLES AXILLARY LYMPH NODES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19306,"CodeDescription":"MAST RAD W\/PECTORAL MUSC AX INT MAM LYMPH NODES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19307,"CodeDescription":"MAST MODF RAD W\/AX LYMPH NOD W\/WO PECT\/ALIS MIN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19316,"CodeDescription":"MASTOPEXY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19318,"CodeDescription":"BREAST REDUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19325,"CodeDescription":"BREAST AUGMENTATION WITH IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19328,"CodeDescription":"REMOVAL INTACT BREAST IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19330,"CodeDescription":"RMVL RUPTURED BREAST IMPLANT W\/IMPLANT CONTENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19340,"CodeDescription":"INSERTION BREAST IMPLANT SAME DAY OF MASTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19342,"CodeDescription":"INSJ\/RPLCMT BREAST IMPLANT SEP DAY MASTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19350,"CodeDescription":"NIPPLE\/AREOLA RECONSTRUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19357,"CodeDescription":"TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19361,"CodeDescription":"BREAST RECONSTRUCTION W\/LATISSIMUS DORSI FLAP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19364,"CodeDescription":"BREAST RECONSTRUCTION W\/FREE FLAP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19367,"CodeDescription":"BREAST RECONSTRUCTION SINGLE PEDICLED TRAM FLAP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19368,"CodeDescription":"BREAST RECONSTRUCTION 1PEDICLED TRAM FLAP ANAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19369,"CodeDescription":"BREAST RECONSTRUCTION BIPEDICLED TRAM FLAP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19370,"CodeDescription":"REVISION PERI-IMPLANT CAPSULE BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19371,"CodeDescription":"PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19380,"CodeDescription":"REVISION OF RECONSTRUCTED BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19396,"CodeDescription":"PREPARATION MOULAGE CUSTOM BREAST IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19499,"CodeDescription":"UNLISTED PROCEDURE BREAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20100,"CodeDescription":"EXPLORATION PENETRATING WOUND SPX NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20101,"CodeDescription":"EXPLORATION PENETRATING WOUND SPX CHEST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20102,"CodeDescription":"EXPL PENETRATING WOUND SPX ABDOMEN\/FLANK\/BACK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20103,"CodeDescription":"EXPLORATION PENETRATING WOUND SPX EXTREMITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20150,"CodeDescription":"EXCISION EPIPHYSEAL BAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20200,"CodeDescription":"BIOPSY MUSCLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20200,"CodeDescription":"BIOPSY MUSCLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20200,"CodeDescription":"BIOPSY MUSCLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20200,"CodeDescription":"BIOPSY MUSCLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20200,"CodeDescription":"BIOPSY MUSCLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20205,"CodeDescription":"BIOPSY MUSCLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20205,"CodeDescription":"BIOPSY MUSCLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20205,"CodeDescription":"BIOPSY MUSCLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20205,"CodeDescription":"BIOPSY MUSCLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20205,"CodeDescription":"BIOPSY MUSCLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20206,"CodeDescription":"BIOPSY MUSCLE PERCUTANEOUS NEEDLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20206,"CodeDescription":"BIOPSY MUSCLE PERCUTANEOUS NEEDLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20206,"CodeDescription":"BIOPSY MUSCLE PERCUTANEOUS NEEDLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20206,"CodeDescription":"BIOPSY MUSCLE PERCUTANEOUS NEEDLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20206,"CodeDescription":"BIOPSY MUSCLE PERCUTANEOUS NEEDLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20220,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20220,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20220,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20220,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20220,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20225,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20225,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20225,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20225,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20225,"CodeDescription":"BIOPSY BONE TROCAR\/NEEDLE DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20240,"CodeDescription":"BIOPSY BONE OPEN SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20240,"CodeDescription":"BIOPSY BONE OPEN SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20240,"CodeDescription":"BIOPSY BONE OPEN SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20240,"CodeDescription":"BIOPSY BONE OPEN SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20240,"CodeDescription":"BIOPSY BONE OPEN SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20245,"CodeDescription":"BIOPSY BONE OPEN DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20245,"CodeDescription":"BIOPSY BONE OPEN DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20245,"CodeDescription":"BIOPSY BONE OPEN DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20245,"CodeDescription":"BIOPSY BONE OPEN DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20245,"CodeDescription":"BIOPSY BONE OPEN DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20250,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20250,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20250,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20250,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20250,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20251,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN LUMBAR\/CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20251,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN LUMBAR\/CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20251,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN LUMBAR\/CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20251,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN LUMBAR\/CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20251,"CodeDescription":"BIOPSY VERTEBRAL BODY OPEN LUMBAR\/CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20500,"CodeDescription":"INJECTION SINUS TRACT THERAPEUTIC SEPARATE PROC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20501,"CodeDescription":"INJECTION SINUS TRACT DIAGNOSTIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20520,"CodeDescription":"REMOVAL FOREIGN BODY MUSCLE\/TENDON SHEATH SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20525,"CodeDescription":"RMVL FOREIGN BODY MUSCLE\/TENDON SHEATH DEEP\/COMP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20526,"CodeDescription":"INJECTION THERAPEUTIC CARPAL TUNNEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20526,"CodeDescription":"INJECTION THERAPEUTIC CARPAL TUNNEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20526,"CodeDescription":"INJECTION THERAPEUTIC CARPAL TUNNEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20526,"CodeDescription":"INJECTION THERAPEUTIC CARPAL TUNNEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20526,"CodeDescription":"INJECTION THERAPEUTIC CARPAL TUNNEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20527,"CodeDescription":"INJECTION ENZYME PALMAR FASCIAL CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20527,"CodeDescription":"INJECTION ENZYME PALMAR FASCIAL CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20527,"CodeDescription":"INJECTION ENZYME PALMAR FASCIAL CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20527,"CodeDescription":"INJECTION ENZYME PALMAR FASCIAL CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20527,"CodeDescription":"INJECTION ENZYME PALMAR FASCIAL CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20550,"CodeDescription":"INJECTION 1 TENDON SHEATH\/LIGAMENT APONEUROSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20550,"CodeDescription":"INJECTION 1 TENDON SHEATH\/LIGAMENT APONEUROSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20550,"CodeDescription":"INJECTION 1 TENDON SHEATH\/LIGAMENT APONEUROSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20550,"CodeDescription":"INJECTION 1 TENDON SHEATH\/LIGAMENT APONEUROSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20550,"CodeDescription":"INJECTION 1 TENDON SHEATH\/LIGAMENT APONEUROSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20551,"CodeDescription":"INJECTION SINGLE TENDON ORIGIN\/INSERTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20551,"CodeDescription":"INJECTION SINGLE TENDON ORIGIN\/INSERTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20551,"CodeDescription":"INJECTION SINGLE TENDON ORIGIN\/INSERTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20551,"CodeDescription":"INJECTION SINGLE TENDON ORIGIN\/INSERTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20551,"CodeDescription":"INJECTION SINGLE TENDON ORIGIN\/INSERTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20552,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 1\/2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20552,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 1\/2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20552,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 1\/2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20552,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 1\/2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20552,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 1\/2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20553,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 3 GE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20553,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 3 GE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20553,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 3 GE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20553,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 3 GE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20553,"CodeDescription":"INJECTION SINGLE\/MLT TRIGGER POINT 3 GE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20555,"CodeDescription":"PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20560,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 1 OR 2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20560,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 1 OR 2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20560,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 1 OR 2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20560,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 1 OR 2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20560,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 1 OR 2 MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20561,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 3 OR MORE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20561,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 3 OR MORE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20561,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 3 OR MORE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20561,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 3 OR MORE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20561,"CodeDescription":"NEEDLE INSERTION W\/O INJECTION 3 OR MORE MUSCLES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20600,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ SMALL JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20600,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ SMALL JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20600,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ SMALL JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20600,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ SMALL JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20600,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ SMALL JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20604,"CodeDescription":"ARTHROCNT ASPIR&\/INJ SMALL JT\/BURSAW\/US REC RPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20604,"CodeDescription":"ARTHROCNT ASPIR&\/INJ SMALL JT\/BURSAW\/US REC RPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20604,"CodeDescription":"ARTHROCNT ASPIR&\/INJ SMALL JT\/BURSAW\/US REC RPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20604,"CodeDescription":"ARTHROCNT ASPIR&\/INJ SMALL JT\/BURSAW\/US REC RPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20604,"CodeDescription":"ARTHROCNT ASPIR&\/INJ SMALL JT\/BURSAW\/US REC RPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20605,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20605,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20605,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20605,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20605,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20606,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20606,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20606,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20606,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20606,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ INTERM JT\/BURS W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20610,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20610,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20610,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20610,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20610,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/O US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20611,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20611,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20611,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20611,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20611,"CodeDescription":"ARTHROCENTESIS ASPIR&\/INJ MAJOR JT\/BURSA W\/US","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20612,"CodeDescription":"ASPIRATION&\/INJECTION GANGLION CYST ANY LOCATJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20612,"CodeDescription":"ASPIRATION&\/INJECTION GANGLION CYST ANY LOCATJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20612,"CodeDescription":"ASPIRATION&\/INJECTION GANGLION CYST ANY LOCATJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20612,"CodeDescription":"ASPIRATION&\/INJECTION GANGLION CYST ANY LOCATJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20612,"CodeDescription":"ASPIRATION&\/INJECTION GANGLION CYST ANY LOCATJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20615,"CodeDescription":"ASPIRATION & INJECTION TREATMENT BONE CYST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20650,"CodeDescription":"INSERTION WIRE\/PIN W\/APPL SKELETAL TRACTION SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20660,"CodeDescription":"APPL CRANIAL TONG\/STRTCTC FRAME W\/REMOVAL SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20661,"CodeDescription":"APPLICATION HALO CRANIAL INCLUDING REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20662,"CodeDescription":"APPLICATION HALO PELVIC INCLUDING REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20663,"CodeDescription":"APPLICATION HALO FEMORAL INCLUDING REMOVAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20664,"CodeDescription":"APPL HALO 6 GE PINS THIN SKULL OSTEOLOGY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20665,"CodeDescription":"REMOVAL TONG\/HALO APPLIED BY ANOTHER INDIVIDUAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20670,"CodeDescription":"REMOVAL IMPLANT SUPERFICIAL SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20680,"CodeDescription":"REMOVAL IMPLANT DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20690,"CodeDescription":"APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20692,"CodeDescription":"APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20693,"CodeDescription":"ADJUSTMENT\/REVJ XTRNL FIXATION SYSTEM REQ ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20694,"CodeDescription":"REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20696,"CodeDescription":"XTRNL FIXJ W\/STEREOTACTIC ADJUSTMENT 1ST & SUBQ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20697,"CodeDescription":"XTRNL FIXJ W\/STRTCTC ADJUSTMENT EXCHANGE STRUT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20700,"CodeDescription":"MANUAL PREP AND INSERTION DEEP DRUG DELIVERY DEV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20701,"CodeDescription":"REMOVAL DEEP DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20701,"CodeDescription":"REMOVAL DEEP DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20701,"CodeDescription":"REMOVAL DEEP DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20701,"CodeDescription":"REMOVAL DEEP DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20701,"CodeDescription":"REMOVAL DEEP DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20702,"CodeDescription":"MANUAL PREP&INSJ INTRAMEDULLARY DRUG DLVR DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20703,"CodeDescription":"REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20703,"CodeDescription":"REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20703,"CodeDescription":"REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20703,"CodeDescription":"REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20703,"CodeDescription":"REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20704,"CodeDescription":"MANUAL PREP&INSJ I-ARTIC DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20705,"CodeDescription":"REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20705,"CodeDescription":"REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20705,"CodeDescription":"REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20705,"CodeDescription":"REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20705,"CodeDescription":"REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20802,"CodeDescription":"REPLANTATION ARM COMPLETE AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20805,"CodeDescription":"REPLANTATION FOREARM COMPLETE AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20808,"CodeDescription":"REPLANTATION HAND COMPLETE AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20816,"CodeDescription":"RPLJ DGT EXCEPT THMB MTCARPHLNGL JT COMPL AMP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20822,"CodeDescription":"RPLJ DGT EXCLUDING THMB SUBLIMIS TDN COMPL AMP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20824,"CodeDescription":"RPLJ THMB CARP\/MTCRPL JT MP JT COMPL AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20827,"CodeDescription":"RPLJ THUMB DISTAL TIP MP JOINT COMPL AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20838,"CodeDescription":"REPLANTATION FOOT COMPLETE AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20900,"CodeDescription":"BONE GRAFT ANY DONOR AREA MINOR\/SMALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20902,"CodeDescription":"BONE GRAFT ANY DONOR AREA MAJOR\/LARGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20910,"CodeDescription":"CARTILAGE GRAFT COSTOCHONDRAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20912,"CodeDescription":"CARTILAGE GRAFT NASAL SEPTUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20920,"CodeDescription":"FASCIA LATA GRAFT BY STRIPPER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20922,"CodeDescription":"FASCIA LATA GRAFT INCISION & AREA EXPOSURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20924,"CodeDescription":"TENDON GRAFT FROM A DISTANCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20930,"CodeDescription":"ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20931,"CodeDescription":"ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20932,"CodeDescription":"OSTEOARTICULAR ALLOGRAFT W\/ARTICULAR SURF & BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20933,"CodeDescription":"HEMICORTICAL INTERCALARY ALLOGRAFT PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20934,"CodeDescription":"INTERCALARY ALLOGRAFT COMPLETE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20936,"CodeDescription":"AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20937,"CodeDescription":"AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20938,"CodeDescription":"AUTOGRAFT SPINE SURGERY BICORT\/TRICORT SEP INC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20939,"CodeDescription":"BONE MARROW ASPIRATION BONE GRFG SPI SURG ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20950,"CodeDescription":"MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20955,"CodeDescription":"BONE GRAFT MICROVASCULAR ANASTOMOSIS FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20956,"CodeDescription":"BONE GRAFT MICROVASCULAR ANAST ILIAC CREST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20957,"CodeDescription":"BONE GRAFT MICROVASCULAR ANAST METATARSAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20962,"CodeDescription":"BONE GRF W\/MVASC ANAST OTH\/THN ILIAC CREST\/METAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20969,"CodeDescription":"FREE OSTQ FLAP W\/MVASC ANAST METAR\/GREAT TOE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20970,"CodeDescription":"FREE OSTQ FLAP W\/MVASC ANASTOMOSIS ILIAC CREST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20972,"CodeDescription":"FREE OSTQ FLAP W\/MVASC ANASTOMOSIS METATARSAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20973,"CodeDescription":"FR OSTQ FLAP W\/MVASC ANAST GRT TOE W\/WEB SPACE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20974,"CodeDescription":"ELECTRICAL STIMULATION BONE HEALING NONINVASIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20975,"CodeDescription":"ELECTRICAL STIMULATION BONE HEALING INVASIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20979,"CodeDescription":"LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20982,"CodeDescription":"ABLATION BONE TUMOR RF PERQ W\/IMG GDN WHEN DONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20983,"CodeDescription":"ABLATJ BONE TUMOR CRYO PERQ W\/IMG GDN WHEN PRFMD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20985,"CodeDescription":"CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20999,"CodeDescription":"UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21010,"CodeDescription":"ARTHROTOMY TEMPOROMANDIBULAR JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21011,"CodeDescription":"EXCISION TUMOR SOFT TISS FACE\/SCALP SUBQ  LT 2CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21012,"CodeDescription":"EXCISION TUMOR SOFT TISS FACE\/SCALP SUBQ 2 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21013,"CodeDescription":"EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL  LT 2CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21014,"CodeDescription":"EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21015,"CodeDescription":"RAD RESECTION TUMOR SOFT TISS FACE\/SCALP LT 2CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21016,"CodeDescription":"RAD RESECTION TUMOR SOFT TISS FACE\/SCALP 2 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21025,"CodeDescription":"EXCISION BONE MANDIBLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21026,"CodeDescription":"EXCISION FACIAL BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21029,"CodeDescription":"REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21030,"CodeDescription":"EXC BENIGN TUMOR\/CYST MAXL\/ZYGOMA ENCL & CURTG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21031,"CodeDescription":"EXCISION TORUS MANDIBULARIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21032,"CodeDescription":"EXCISION MAXILLARY TORUS PALATINUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21034,"CodeDescription":"EXCISION MALIGNANT TUMOR MAXILLA\/ZYGOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21040,"CodeDescription":"EXCISION BENIGN TUMOR\/CYST MANDIBLE ENCL & CURT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21044,"CodeDescription":"EXCISION MALIGNANT TUMOR MANDIBLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21045,"CodeDescription":"EXCISION MALIGNANT TUMOR MANDIBLE RADICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21046,"CodeDescription":"EXC BENIGN TUMOR\/CYST MNDBL INTRA-ORAL OSTEOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21047,"CodeDescription":"EXC B9 TUM\/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21048,"CodeDescription":"EXC BENIGN TUMOR\/CYST MAXL INTRA-ORAL OSTEOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21049,"CodeDescription":"EXC B9 TUM\/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21050,"CodeDescription":"CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21060,"CodeDescription":"MENISCECTOMY PRTL\/COMPL TEMPOROMANDIBULAR JT SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21070,"CodeDescription":"CORONOIDECTOMY SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21073,"CodeDescription":"MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21100,"CodeDescription":"APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21110,"CodeDescription":"APPL INTERDENTAL FIXATION DEVICE NON-FX\/DISLC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21116,"CodeDescription":"INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21120,"CodeDescription":"GENIOPLASTY AUGMENTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21121,"CodeDescription":"GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21122,"CodeDescription":"GENIOPLASTY 2 GE SLIDING OSTEOTOMIES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21123,"CodeDescription":"GENIOP SLIDING AGMNTJ W\/INTERPOSAL BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21127,"CodeDescription":"AGMNTJ MNDBLR BDY\/ANGL W\/GRF ONLAY\/INTERPOSAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21137,"CodeDescription":"REDUCTION FOREHEAD CONTOURING ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21138,"CodeDescription":"RDCTJ FHD CNTRG & PROSTHETIC MATRL\/BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21139,"CodeDescription":"RDCTJ FHD CNTRG & SETBACK ANT FRONTAL SINUS WALL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21141,"CodeDescription":"RCNSTJ MIDFACE LEFORT I 1 PIECE W\/O BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21142,"CodeDescription":"RCNSTJ MIDFACE LEFORT I 2 PIECES W\/O BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21143,"CodeDescription":"RCNSTJ MIDFACE LEFORT I 3 GE PIECE W\/O BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21145,"CodeDescription":"RCNSTJ MIDFACE LEFORT I 1 PIECE W\/BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21146,"CodeDescription":"RCNSTJ MIDFACE LEFORT I 2 PIECES W\/BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21147,"CodeDescription":"RCNSTJ MIDFACE LEFORT I 3 GE PIECE W\/BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21150,"CodeDescription":"RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21151,"CodeDescription":"RCNSTJ MIDFACE LEFORT II W\/BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21154,"CodeDescription":"RCNSTJ MIDFACE LEFORT III W\/O LEFORT I","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21155,"CodeDescription":"RCNSTJ MIDFACE LEFORT III W\/LEFORT I","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21159,"CodeDescription":"RCNSTJ MIDFACE LEFORT III W\/FHD W\/O LEFORT I","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21160,"CodeDescription":"RCNSTJ MIDFACE LEFORT III W\/FHD W\/LEFORT I","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21172,"CodeDescription":"RCNSTJ SUPERIOR-LATERAL ORBITAL RIM & LOWER FHD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21175,"CodeDescription":"RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS & LWR FHD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21179,"CodeDescription":"RCNSTJ FOREHEAD &\/ SUPRAORB RIMS W\/ALGRF\/PROSTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21180,"CodeDescription":"RCNSTJ FOREHEAD &\/ SUPRAORBITAL RIMS W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21181,"CodeDescription":"RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21182,"CodeDescription":"RCNSTJ ORBIT\/FHD\/NASETHMD EXCBONE TUM GRF LT 40SQCM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21183,"CodeDescription":"RCNSTJ ORBIT\/FHD\/NASETHMD EXC BONE GRF GT 40  LT 80","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21184,"CodeDescription":"RCNSTJ ORBIT\/FHD\/NASETHMD EXC BONE TUM GRF GT 80SQ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21188,"CodeDescription":"RCNSTJ MDFC OTH\/THN LEFORT OSTEOT & BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21193,"CodeDescription":"RCNSTJ MNDBLR RAMI HRZNTL\/VER\/C\/L OSTEOT W\/O GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21194,"CodeDescription":"RCNSTJ MNDBLR RAMI HRZNTL\/VER\/C\/L OSTEOT W\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21195,"CodeDescription":"RCNSTJ MNDBLR RAMI&\/BODY SGTL SPLT W\/O INT RGD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21196,"CodeDescription":"RCNSTJ MNDBLR RAMI&\/BDY SGTL SPLT W\/INT RGD FI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21198,"CodeDescription":"OSTEOTOMY MANDIBLE SEGMENTAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21199,"CodeDescription":"OSTEOTOMY MANDIBLE SGMTL W\/GENIOGLOSSUS ADVMNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21206,"CodeDescription":"OSTEOTOMY MAXILLA SEGMENTAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21208,"CodeDescription":"OSTEOPLASTY FACIAL BONES AUGMENTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21209,"CodeDescription":"OSTEOPLASTY FACIAL BONES REDUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21210,"CodeDescription":"GRAFT BONE NASAL\/MAXILLARY\/MALAR AREAS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21215,"CodeDescription":"GRAFT BONE MANDIBLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21230,"CodeDescription":"GRAFT RIB CRTLG AUTOGENOUS FACE\/CHIN\/NOSE\/EAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21235,"CodeDescription":"GRAFT EAR CRTLG AUTOGENOUS NOSE\/EAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21240,"CodeDescription":"ARTHRP TEMPOROMANDIBULAR JOINT W\/WO AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21242,"CodeDescription":"ARTHROPLASTY TEMPOROMANDIBULAR JT W\/ALLOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21243,"CodeDescription":"ARTHRP TMPRMAND JOINT W\/PROSTHETIC REPLACEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21244,"CodeDescription":"RCNSTJ MNDBL XTRORAL W\/TRANSOSTEAL BONE PLATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21245,"CodeDescription":"RCNSTJ MNDBL\/MAXL SUBPRIOSTEAL IMPLANT PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21246,"CodeDescription":"RCNSTJ MNDBL\/MAXL SUBPRIOSTEAL IMPLANT COMPLETE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21247,"CodeDescription":"RCNSTJ MNDBLR CONDYLE W\/BONE CARTLG AUTOGRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21248,"CodeDescription":"RCNSTJ MANDIBLE\/MAXL ENDOSTEAL IMPLANT PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21249,"CodeDescription":"RCNSTJ MANDIBLE\/MAXL ENDOSTEAL IMPLANT COMPLETE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21255,"CodeDescription":"RCNSTJ ZYGMTC ARCH\/GLENOID FOSSA W\/BONE CARTLG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21256,"CodeDescription":"RECONSTRUCTION ORBIT W\/OSTEOTOMIES & BONE GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21260,"CodeDescription":"PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21261,"CodeDescription":"PERIORBITAL OSTEOTOMIES W\/BONE GRAFTS ICRA & XTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21263,"CodeDescription":"PERIORBITAL OSTEOTOMIES W\/BONE GRAFTS W\/FOREHEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21267,"CodeDescription":"ORBITAL REPOSITIONING W\/BONE GRAFTS EXTRACRANIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21268,"CodeDescription":"ORBITAL REPOSITIONING W\/BONE GRAFTS ICRA & XTRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21270,"CodeDescription":"MALAR AUGMENTATION PROSTHETIC MATERIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21275,"CodeDescription":"SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21280,"CodeDescription":"MEDIAL CANTHOPEXY SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21282,"CodeDescription":"LATERAL CANTHOPEXY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21295,"CodeDescription":"REDUCTION MASSETER MUSCLE & BONE EXTRAORAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21296,"CodeDescription":"REDUCTION MASSETER MUSCLE & BONE INTRAORAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21299,"CodeDescription":"UNLISTED CRANIOFACIAL & MAXILLOFACIAL PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21315,"CodeDescription":"CLOSED TX NASAL BONE FX W\/MNPJ W\/O STABILIZATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21320,"CodeDescription":"CLOSED TX NASAL BONE FX W\/MNPJ W\/STABILIZATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21325,"CodeDescription":"OPEN TREATMENT NASAL FRACTURE UNCOMPLICATED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21330,"CodeDescription":"OPEN TX NASAL FX COMP W\/INT&\/XTRNL SKELETAL FI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21335,"CodeDescription":"OPEN TX NASAL FX W\/CONCOMITANT OPTX FXD SEPTUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21336,"CodeDescription":"OPEN TX NASAL SEPTAL FRACTURE W\/WO STABILIZATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21337,"CodeDescription":"CLOSED TX NASAL SEPTAL FRACT W\/WO STABILIZATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21338,"CodeDescription":"OPEN TX NASOETHMOID FX W\/O EXTERNAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21339,"CodeDescription":"OPEN TX NASOETHMOID FX W\/EXTERNAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21340,"CodeDescription":"PERCUTANEOUS TX NASOETHMOID COMPLEX FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21343,"CodeDescription":"OPEN TX DEPRESSED FRONTAL SINUS FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21344,"CodeDescription":"OPEN TX COMPLICATED FRONTAL SINUS FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21345,"CodeDescription":"CLOSED TX NASOMAXILLARY COMPLEX FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21346,"CodeDescription":"OPTX NASOMAX CPLX FX LEFT II TYPE W\/WIRG & FXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21347,"CodeDescription":"OPTX NASOMAX CPLX FX LEFT II TYPE REQ MLT OPN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21348,"CodeDescription":"OPTX NASOMAX CPLX FX LEFT II TYPE W\/BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21355,"CodeDescription":"PERCUTANEOUS TX MALAR AREA FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21356,"CodeDescription":"OPEN TX DEPRESSED ZYGOMATIC ARCH FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21360,"CodeDescription":"OPEN TX DEPRESSED MALAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21365,"CodeDescription":"OPEN TX COMP FX MALAR W\/INTERNAL FX&MULT SURG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":21366,"CodeDescription":"OPEN TX COMP FRACTURE MALAR AREA W\/BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21385,"CodeDescription":"OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21386,"CodeDescription":"OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21387,"CodeDescription":"OPEN TX ORBITAL FLOOR BLOWOUT FX COMBINED APPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21390,"CodeDescription":"OPTX ORB FLOOR BLWT FX PRI\/BITAL APPR W\/ALLPLSTC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21395,"CodeDescription":"OPTX ORB FLOOR BLWT FX PRI\/BITAL APPR W\/BONE GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21400,"CodeDescription":"CLSD TX FX ORBIT EXCEPT BLOWOUT W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21401,"CodeDescription":"CLOSED TX FX ORBIT EXCEPT BLOWOUT W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21406,"CodeDescription":"OPEN TX FX ORBIT EXCEPT BLOWOUT W\/O IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21407,"CodeDescription":"OPEN TX FX ORBIT EXCEPT BLOWOUT W\/IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21408,"CodeDescription":"OPEN TX FX ORBIT EXCEPT BLOWOUT W\/BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21421,"CodeDescription":"CLOSED TX PALATAL\/MAXILLARY FX W\/FIXATION\/SPLINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21422,"CodeDescription":"OPEN TREATMENT PALATAL\/MAXILLARY FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21423,"CodeDescription":"OPEN TX PALATAL\/MAXILLARY FX COMP MULTIPLE APPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21431,"CodeDescription":"CLOSED TX CRANIOFACIAL SEPARATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21432,"CodeDescription":"OPEN TX CRANIOFACIAL SEP W\/WIRING&\/INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21433,"CodeDescription":"OPEN TX CRANIOFACIAL SEP COMPLICATED MLT APPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21435,"CodeDescription":"OPEN TX CRANIOFACIAL SEP COMP W\/INT&\/XTRNL FIX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21436,"CodeDescription":"OPTX CRNFCL SEP LFT III TYP COMP INT FIXJ W\/BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21440,"CodeDescription":"CLTX MANDIBULAR\/MAXILLARY ALVEOLAR RIDGE FX SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21445,"CodeDescription":"OPTX MANDIBULAR\/MAXILLARY ALVEOLAR RIDGE FX SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21450,"CodeDescription":"CLOSED TX MANDIBULAR FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21451,"CodeDescription":"CLOSED TX MANDIBULAR FRACTURE W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21452,"CodeDescription":"PERCUTANEOUS TX MANDIBULAR FX W\/EXTERNAL FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21453,"CodeDescription":"CLOSED TX MANDIBULAR FX W\/INTERDENTAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21454,"CodeDescription":"OPEN TX MANDIBULAR FX W\/EXTERNAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21461,"CodeDescription":"OPEN TX MANDIBULAR FX W\/O INTERDENTAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21462,"CodeDescription":"OPEN TX MANDIBULAR FX W\/INTERDENTAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21465,"CodeDescription":"OPEN TREATMENT MANDIBULAR CONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21470,"CodeDescription":"OPTX COMP MANDIBULAR FX MLT APPR W\/INT FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21480,"CodeDescription":"CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST\/SBSQ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21485,"CodeDescription":"CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST\/SBSQ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21490,"CodeDescription":"OPEN TREATMENT TEMPOROMANDIBULAR DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21497,"CodeDescription":"INTERDENTAL WIRING OTHER THAN FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21499,"CodeDescription":"UNLISTED MUSCULOSKELETAL PROCEDURE HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21501,"CodeDescription":"I&D DEEP ABSC\/HMTMA SOFT TISSUE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21502,"CodeDescription":"I&D DP ABSC\/HMTMA SOFT TISS NCK\/THORAX PRTL RI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21510,"CodeDescription":"INCISION DEEP OPENING BONE CORTEX THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21550,"CodeDescription":"BIOPSY SOFT TISSUE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21550,"CodeDescription":"BIOPSY SOFT TISSUE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21550,"CodeDescription":"BIOPSY SOFT TISSUE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21550,"CodeDescription":"BIOPSY SOFT TISSUE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21550,"CodeDescription":"BIOPSY SOFT TISSUE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21552,"CodeDescription":"EXC TUMOR SOFT TIS NECK\/ANT THORAX SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21554,"CodeDescription":"EXC TUMOR SOFT TISSUE NECK\/THORAX SUBFASC 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21555,"CodeDescription":"EXC TUMOR SOFT TISSUE NECK\/ANT THORAX SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21556,"CodeDescription":"EXC TUMOR SOFT TISS NECK\/THORAX SUBFASCIAL  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21557,"CodeDescription":"RAD RESECT TUMOR SOFT TISS NECK\/ANT THORAX  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21558,"CodeDescription":"RAD RESECT TUMOR SOFT TISS NECK\/ANT THORAX 5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21600,"CodeDescription":"EXCISION RIB PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21601,"CodeDescription":"EXCISION CHEST WALL TUMOR INCLUDING RIBS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21602,"CodeDescription":"EXCISION CH WAL TUM W\/RIB W\/O MEDSTNL LYMPHADEC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21603,"CodeDescription":"EXCISION CH WAL TUM W\/RIB W\/MEDSTNL LYMPHADEC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21610,"CodeDescription":"COSTOTRANSVERSECTOMY SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21615,"CodeDescription":"EXCISION 1ST &\/CERVICAL RIB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21616,"CodeDescription":"EXCISION 1ST &\/CERVICAL RIB W\/SYMPATHECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21620,"CodeDescription":"OSTECTOMY STERNUM PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21627,"CodeDescription":"STERNAL DEBRIDEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21630,"CodeDescription":"RADICAL RESECTION STERNUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21632,"CodeDescription":"RADICAL RESECTION STERNUM W\/MEDSTNL LMPHADEC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21685,"CodeDescription":"HYOID MYOTOMY & SUSPENSION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21700,"CodeDescription":"DIVISION SCALENUS ANTICUS W\/O RESCJ CERVICAL RIB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21705,"CodeDescription":"DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21720,"CodeDescription":"DIVISION STERNOCLEIDOMASTOID OPEN W\/O CAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21725,"CodeDescription":"DIVISION STERNOCLEIDOMASTOID OPEN W\/CAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21740,"CodeDescription":"REPAIR PECTUS EXCAVATUM\/CARINATUM OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21742,"CodeDescription":"REPAIR PECTUS EXCAVATM\/CARINATM MINLY W\/O THRSC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21743,"CodeDescription":"REPAIR PECTUS EXCAVATM\/CARINATM MINLY W\/THRSC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21750,"CodeDescription":"CLOSE MEDIAN STERNOTOMY SEP W\/WO DEBRIDEMENT SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21811,"CodeDescription":"OPEN TX RIB FX W\/FIXJ THORACOSCOPIC VIS 1-3 RIBS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21812,"CodeDescription":"OPEN TX RIB FX W\/FIXJ THORACOSCOPIC VIS 4-6 RIBS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21813,"CodeDescription":"OPEN TX RIB FX W\/FIXJ THORACOSCOPIC VIS 7+ RIBS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21820,"CodeDescription":"CLOSED TREATMENT STERNUM FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21825,"CodeDescription":"OPEN TX STERNUM FRACTURE W\/WO SKELETAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21899,"CodeDescription":"UNLISTED PROCEDURE NECK\/THORAX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21920,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21920,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21920,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21920,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21920,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21925,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21925,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21925,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21925,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21925,"CodeDescription":"BIOPSY SOFT TISSUE BACK\/FLANK DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":21930,"CodeDescription":"EXCISION TUMOR SOFT TISSUE BACK\/FLANK SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21931,"CodeDescription":"EXCISION TUMOR SOFT TIS BACK\/FLANK SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21932,"CodeDescription":"EXC TUMOR SOFT TISS BACK\/FLANK SUBFASCIAL  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21933,"CodeDescription":"EXC TUMOR SOFT TISS BACK\/FLANK SUBFASCIAL 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21935,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE BACK\/FLANK  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21936,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE BACK\/FLANK 5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22010,"CodeDescription":"I&D DEEP ABSCESS PST SPINE CRV THRC\/CERVICOTHR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22015,"CodeDescription":"I&D DEEP ABSCESS PST SPINE LUMBAR SAC\/LUMBOSAC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22100,"CodeDescription":"PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22101,"CodeDescription":"PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22102,"CodeDescription":"PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22103,"CodeDescription":"PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22110,"CodeDescription":"PRTL EXC VRT BDY B1Y LES W\/O SPI CORD 1 SGM CRV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22112,"CodeDescription":"PRTL EXC VRT BDY B1Y LES W\/O SPI CORD 1 SGM THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22114,"CodeDescription":"PRTL EXC VRT BDY B1Y LES W\/O SPI CORD 1 SGM LMBR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22116,"CodeDescription":"PRTL EXC VRT BDY B1Y LES W\/O SPI CORD 1 SGM EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22206,"CodeDescription":"OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22207,"CodeDescription":"OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22208,"CodeDescription":"OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22210,"CodeDescription":"OSTEOTOMY SPINE PST\/PSTLAT APPR 1 VRT SGM CRV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22212,"CodeDescription":"OSTEOTOMY SPINE PST\/PSTLAT APPR 1 VRT SGM THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22214,"CodeDescription":"OSTEOTOMY SPINE PST\/PSTLAT APPR 1 VRT SGM LMBR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22216,"CodeDescription":"OSTEOT SPI PST\/PSTLAT APPR 1 VRT SGM EA VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22220,"CodeDescription":"OSTEOTOMY SPINE W\/DSC ANT APPR 1 VRT SGM CRV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22222,"CodeDescription":"OSTEOTOMY SPINE W\/DSC ANT APPR 1 VRT SGM THRC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22224,"CodeDescription":"OSTEOTOMY SPINE W\/DSC ANT APPR 1 VRT SGM LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22226,"CodeDescription":"OSTEOTOMY SPINE W\/DSC ANT APPR 1 VRT SGM EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22310,"CodeDescription":"CLTX VRT BDY FX W\/O MANJ REQ&W\/CSTING\/BRACING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22315,"CodeDescription":"CLTX VRT FX&\/DISLC CSTING\/BRACING MANJ\/TRCJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22318,"CodeDescription":"OPTX&\/RDCTJ ODNTD FX&\/DISLC ANT FIXJ W\/O GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22319,"CodeDescription":"OPTX&\/RDCTJ ODNTD FX&\/DISLC ANT W\/INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22325,"CodeDescription":"OPTX&\/RDCTJ VRT FX&\/DISLC PST 1 VRT SGM LM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22326,"CodeDescription":"OPTX&\/RDCTJ VRT FX&\/DISLC PST 1 VRT SGM CR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22327,"CodeDescription":"OPTX&\/RDCTJ VRT FX&\/DISLC PST 1 VRT SGM TH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22328,"CodeDescription":"OPTX&\/RDCTJ VRT FX&\/DISLC PST 1 VRT SGM EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22505,"CodeDescription":"MANIPULATION SPINE REQUIRING ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22510,"CodeDescription":"PERQ VERTEBROPLASTY UNI\/BI INJX CERVICOTHORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22511,"CodeDescription":"PERQ VERTEBROPLASTY UNI\/BI INJECTION LUMBOSACRAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22512,"CodeDescription":"VERTEBROPLASTY EACH ADDL CERVICOTHOR\/LUMBOSACRAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22513,"CodeDescription":"PERQ VERT AGMNTJ CAVITY CRTJ UNI\/BI CANNULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22514,"CodeDescription":"PERQ VERT AGMNTJ CAVITY CRTJ UNI\/BI CANNULJ LMBR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22515,"CodeDescription":"PERQ VERT AGMNTJ CAVITY CRTJ UNI\/BI CANNULJ EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22532,"CodeDescription":"ARTHRODESIS LATERAL EXTRACAVITARY THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22533,"CodeDescription":"ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22534,"CodeDescription":"ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC\/LMBR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22548,"CodeDescription":"ARTHRD ANT TRANSORL\/XTRORAL C1-C2 W\/WO EXC ODNTD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22551,"CodeDescription":"ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22552,"CodeDescription":"ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22554,"CodeDescription":"ARTHRD ANT INTERBODY MIN DSC CRV BELOW C2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22556,"CodeDescription":"ARTHRD ANT INTERBODY MIN DSC THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22558,"CodeDescription":"ARTHRD ANT INTERBODY MIN DSC LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22585,"CodeDescription":"ARTHRD ANT NTRBD MIN DSC EA ADDL INTERSPACE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22586,"CodeDescription":"ARTHRODESIS PRESACRAL NTRBDY DSC W\/INSTRMJ L5-S1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22590,"CodeDescription":"ARTHRODESIS POSTERIOR CRANIOCERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22595,"CodeDescription":"ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22600,"CodeDescription":"ARTHRD PST\/PSTLAT TQ 1NTRSPC CRV BELW C2 SEGMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22610,"CodeDescription":"ARTHRODESIS POSTERIOR\/PSTLAT TQ 1NTRSPC THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22612,"CodeDescription":"ARTHRODESIS POSTERIOR\/PSTLAT TQ 1NTRSPC LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22614,"CodeDescription":"ARTHRODESIS PST\/PSTLAT TQ 1NTRSPC EA ADDL NTRSPC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22630,"CodeDescription":"ARTHRODESIS POSTERIOR INTERBODY 1 NTRSPC LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22632,"CodeDescription":"ARTHRODESIS POSTERIOR INTERBODY 1 NTRSPC EA ADDL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22633,"CodeDescription":"ARTHRODESIS COMBINED TQ 1NTRSPC LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22634,"CodeDescription":"ARTHRODESIS CMBN TQ 1NTRSPC EACH ADDITIONAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22800,"CodeDescription":"ARTHRODESIS POSTERIOR SPINAL DFRM <6 VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22802,"CodeDescription":"ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22804,"CodeDescription":"ARTHRODESIS POSTERIOR SPINAL DFRM 13+ VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22808,"CodeDescription":"ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22810,"CodeDescription":"ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22812,"CodeDescription":"ARTHRODESIS ANTERIOR SPINAL DFRM 8+ VRT SGM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22818,"CodeDescription":"KYPHECTOMY SINGLE OR TWO SEGMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22819,"CodeDescription":"KYPHECTOMY 3 OR MORE SEGMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22830,"CodeDescription":"EXPLORATION SPINAL FUSION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22840,"CodeDescription":"POSTERIOR NON-SEGMENTAL INSTRUMENTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22841,"CodeDescription":"INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22842,"CodeDescription":"POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22843,"CodeDescription":"POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22844,"CodeDescription":"POSTERIOR SEGMENTAL INSTRUMENTATION 13 GE VRT SE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22845,"CodeDescription":"ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22846,"CodeDescription":"ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22847,"CodeDescription":"ANTERIOR INSTRUMENTATION 8 GE VERTEBRAL SEGMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22848,"CodeDescription":"PELVIC FIXATION OTHER THAN SACRUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22849,"CodeDescription":"REINSERTION SPINAL FIXATION DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22850,"CodeDescription":"REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22852,"CodeDescription":"REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22853,"CodeDescription":"INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC W\/ARTHRD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22854,"CodeDescription":"INSJ BIOMCHN DEV VRT CORPECTOMY DEFECT W\/ARTHRD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22855,"CodeDescription":"REMOVAL ANTERIOR INSTRUMENTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22856,"CodeDescription":"TOTAL DISC ARTHRP ANT DSC 1 INTERSPACE CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22857,"CodeDescription":"TOTAL DISC ARTHRP ANT SINGLE INTERSPACE LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22858,"CodeDescription":"TOTAL DISC ARTHRP ANT DSC 2ND LEVEL CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22859,"CodeDescription":"INSJ BIOMCHN DEV NTRVRT DISC SPACE W\/O ARTHRD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22861,"CodeDescription":"REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22862,"CodeDescription":"REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22864,"CodeDescription":"RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22865,"CodeDescription":"RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22867,"CodeDescription":"INSJ STABLJ DEV W\/DCMPRN LUMBAR SINGLE LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22868,"CodeDescription":"INSJ STABLJ DEV W\/DCMPRN LUMBAR SECOND LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22869,"CodeDescription":"INSJ STABLJ DEV W\/O DCMPRN LUMBAR SINGLE LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22870,"CodeDescription":"INSJ STABLJ DEV W\/O DCMPRN LUMBAR SECOND LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22899,"CodeDescription":"UNLISTED PROCEDURE SPINE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22900,"CodeDescription":"EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22901,"CodeDescription":"EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22902,"CodeDescription":"EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22903,"CodeDescription":"EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22904,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE ABDL WALL  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22905,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22999,"CodeDescription":"UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23000,"CodeDescription":"REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23020,"CodeDescription":"CAPSULAR CONTRACTURE RELEASE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23030,"CodeDescription":"I&D SHOULDER DEEP ABSCESS\/HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23031,"CodeDescription":"I&D SHOULDER INFECTED BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23035,"CodeDescription":"INCISION BONE CORTEX SHOULDER AREA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23040,"CodeDescription":"ARTHROTOMY GLENOHUMERAL JT EXPL\/DRG\/RMVL FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23044,"CodeDescription":"ARTHRT ACROMCLAV STRNCLAV JT EXPL\/DRG\/RMVL FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23065,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23065,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23065,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23065,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23065,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23066,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23066,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23066,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23066,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23066,"CodeDescription":"BIOPSY SOFT TISSUE SHOULDER DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23071,"CodeDescription":"EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23073,"CodeDescription":"EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23075,"CodeDescription":"EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23076,"CodeDescription":"EXC TUMOR SOFT TISS SHOULDER SUBFASC  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23077,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE SHOULDER  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23078,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23100,"CodeDescription":"ARTHROTOMY GLENOHUMERAL JOINT W\/BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23100,"CodeDescription":"ARTHROTOMY GLENOHUMERAL JOINT W\/BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23100,"CodeDescription":"ARTHROTOMY GLENOHUMERAL JOINT W\/BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23100,"CodeDescription":"ARTHROTOMY GLENOHUMERAL JOINT W\/BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23100,"CodeDescription":"ARTHROTOMY GLENOHUMERAL JOINT W\/BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":23101,"CodeDescription":"ARTHRT ACROMCLAV\/STRNCLAV JT W\/BX&\/EXC CRTLG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23105,"CodeDescription":"ARTHRT GLENOHUMRL JT W\/SYNOVECTOMY W\/WO BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23106,"CodeDescription":"ARTHRT GLENOHUMRL JT STRNCLAV JT W\/SYNVCT W\/WOBX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23107,"CodeDescription":"ARTHRT GLENOHMRL JT W\/JT EXPL W\/WO RMVL LOOSE\/FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23120,"CodeDescription":"CLAVICULECTOMY PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23125,"CodeDescription":"CLAVICULECTOMY TOTAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23130,"CodeDescription":"PARTIAL REPAIR OR REMOVAL OF SHOULDER BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23140,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUMOR CLAV\/SCAPULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23145,"CodeDescription":"EXC\/CURTG BONE CST\/B9 TUM CLAV\/SCAPULA W\/AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23146,"CodeDescription":"EXC\/CURTG BONE CST\/B9 TUM CLAV\/SCAPULA W\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23150,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUMOR PROX HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23155,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUM PROX HUM W\/AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23156,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUM PROX HUM W\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23170,"CodeDescription":"SEQUESTRECTOMY CLAVICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23172,"CodeDescription":"SEQUESTRECTOMY SCAPULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23174,"CodeDescription":"SEQUESTRECTOMY HUMERAL HEAD SURGERY NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23180,"CodeDescription":"PARTIAL EXCISION BONE CLAVICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23182,"CodeDescription":"PARTIAL EXCISION BONE SCAPULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23184,"CodeDescription":"PARTIAL EXCISION BONE PROXIMAL HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23190,"CodeDescription":"OSTECTOMY SCAPULA PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23195,"CodeDescription":"RESECTION HUMERAL HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23200,"CodeDescription":"RADICAL RESECTION TUMOR CLAVICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23210,"CodeDescription":"RADICAL RESECTION TUMOR SCAPULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23220,"CodeDescription":"RADICAL RESECTION BONE TUMOR PROXIMAL HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23330,"CodeDescription":"REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23333,"CodeDescription":"REMOVAL SHOULDER FOREIGN BODY DEEP SUBFASCIAL\/IM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23334,"CodeDescription":"PROSTHESIS REMOVAL HUMERAL\/GLENOID COMPONENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23335,"CodeDescription":"PROSTHESIS REMOVAL HUMERAL AND GLENOID COMPONENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23350,"CodeDescription":"INJECTION SHOULDER ARTHROGRAPHY\/ CT\/MRI ARTHG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23395,"CodeDescription":"MUSCLE TRANSFER SHOULDER\/UPPER ARM SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23397,"CodeDescription":"MUSCLE TRANSFER SHOULDER\/UPPER ARM MULTIPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23400,"CodeDescription":"SCAPULOPEXY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23405,"CodeDescription":"TENOTOMY SHOULDER AREA 1 TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23406,"CodeDescription":"TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23410,"CodeDescription":"OPEN REPAIR OF ROTATOR CUFF ACUTE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23412,"CodeDescription":"OPEN REPAIR OF ROTATOR CUFF CHRONIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23415,"CodeDescription":"CORACOACROMIAL LIGAMENT RELEAS W\/WOACROMIOPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23420,"CodeDescription":"RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23430,"CodeDescription":"TENODESIS LONG TENDON BICEPS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23450,"CodeDescription":"CAPSULORRHAPHY ANTERIOR PUTTI-PLATT\/MAGNUSON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23455,"CodeDescription":"CAPSULORRHAPHY ANTERIOR W\/LABRAL REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23460,"CodeDescription":"CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23462,"CodeDescription":"CAPSULORRHAPHY ANTERIOR W\/CORACOID PROCESS TR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23465,"CodeDescription":"CAPSULORRHAPHY GLENOHUMERAL JT PST W\/WO BONE BLK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23466,"CodeDescription":"CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23470,"CodeDescription":"ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23472,"CodeDescription":"ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23473,"CodeDescription":"REVIS SHOULDER ARTHRPLSTY HUMERAL\/GLENOID COMPNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23474,"CodeDescription":"REVIS SHOULDER ARTHRPLSTY HUMERAL&GLENOID COMPNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23480,"CodeDescription":"OSTEOTOMY CLAVICLE W\/WO INTERNAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23485,"CodeDescription":"OSTEOTOMY CLAV W\/WO INT FIXJ W\/BONE GRF NON\/MAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23490,"CodeDescription":"PROPH TX W\/WO METHYLMETHACRYLATE CLAVICLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23491,"CodeDescription":"PROPH TX W\/WO METHYLMETHACRYLATE PROX HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23500,"CodeDescription":"CLSD TX CLAVICULAR FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23505,"CodeDescription":"CLSD TX CLAVICULAR FRACTURE W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23515,"CodeDescription":"OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23520,"CodeDescription":"CLSD TX STERNOCLAVICULAR DISLC W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23525,"CodeDescription":"CLOSED TX STERNOCLAVICULAR DISLC W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23530,"CodeDescription":"OPEN TX STERNOCLAVICULAR DISLC ACUTE\/CHRONIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23532,"CodeDescription":"OPTX STRNCLAV DISLC ACUTE\/CHRONIC W\/FASCIAL GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23540,"CodeDescription":"CLSD TX ACROMIOCLAVICULAR DISLC W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23545,"CodeDescription":"CLSD TX ACROMIOCLAVICULAR DISLC W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23550,"CodeDescription":"OPEN TX ACROMIOCLAVICULAR DISLC ACUTE\/CHRONIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23552,"CodeDescription":"OPTX ACROMCLAV DISLC ACUTE\/CHRONIC W\/FASCIAL GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23570,"CodeDescription":"CLOSED TX SCAPULAR FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23575,"CodeDescription":"CLTX SCAPULAR FX W\/MANJ W\/WO SKELETAL TRACTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23585,"CodeDescription":"OPEN TX SCAPULAR FX W\/INTERNAL FIXATION IF PFRMD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23600,"CodeDescription":"CLTX PROXIMAL HUMERAL FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23605,"CodeDescription":"CLTX PROX HUMRL FX W\/MANJ W\/WO SKELETAL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23615,"CodeDescription":"OPEN TREATMENT PROXIMAL HUMERAL FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23616,"CodeDescription":"OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23620,"CodeDescription":"CLTX GREATER HUMERAL TUBEROSITY FX W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23625,"CodeDescription":"CLTX GRTER HUMERAL TUBEROSITY FX W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23630,"CodeDescription":"OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23650,"CodeDescription":"CLSD TX SHOULDER DISLC W\/MANIPULATION W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23655,"CodeDescription":"CLSD TX SHOULDER DISLC W\/MANIPULATION REQ ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23660,"CodeDescription":"OPEN TX ACUTE SHOULDER DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23665,"CodeDescription":"CLTX SHOULDER DISLC W\/FX HUMERAL TUBRST W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23670,"CodeDescription":"OPEN TX SHOULDER DISLC W\/HUMERAL TUBEROSITY FX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23675,"CodeDescription":"CLTX SHOULDER DISLC W\/SURG\/ANTMCL NECK FX W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23680,"CodeDescription":"OPEN TX SHOULDER DISLOCATION W\/NECK FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23700,"CodeDescription":"MANJ W\/ANES SHOULDER JOINT W\/FIXATION APPARATUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23800,"CodeDescription":"ARTHRODESIS GLENOHUMERAL JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23802,"CodeDescription":"ARTHRODESIS GLENOHUMERAL JT W\/AUTOGENOUS GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23900,"CodeDescription":"INTERTHORACOSCAPULAR AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23920,"CodeDescription":"DISARTICULATION SHOULDER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23921,"CodeDescription":"DISRTCJ SHOULDER SECONDARY CLSR\/SCAR REVISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23929,"CodeDescription":"UNLISTED PROCEDURE SHOULDER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23930,"CodeDescription":"I&D UPPER ARM\/ELBOW DEEP ABSCESS\/HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23931,"CodeDescription":"INCISION&DRAINAGE UPPER ARM\/ELBOW BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":23935,"CodeDescription":"INC DEEP W\/OPENING BONE CORTEX HUMERUS\/ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24000,"CodeDescription":"ARTHRT ELBOW W\/EXPLORATION DRAINAGE\/REMOVAL FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24006,"CodeDescription":"ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24065,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24065,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24065,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24065,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24065,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24066,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24066,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24066,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24066,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24066,"CodeDescription":"BIOPSY SOFT TISSUE UPPER ARM\/ELBOW AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24071,"CodeDescription":"EXC TUMOR SOFT TISSUE UPPER ARM\/ELBOW SUBQ 3CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24073,"CodeDescription":"EXC TUMOR SOFT TISS UPPER ARM\/ELBW SUBFASC 5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24075,"CodeDescription":"EXC TUMOR SOFT TISS UPPER ARM\/ELBOW SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24076,"CodeDescription":"EXC TUMOR SOFT TISS UPR ARM\/ELBOW SUBFASC  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24077,"CodeDescription":"RAD RESECT TUMOR SOFT TISS UPPER ARM\/ELBOW  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24079,"CodeDescription":"RAD RESECT TUMOR SOFT TISS UPPER ARM\/ELBOW 5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24100,"CodeDescription":"ARTHROTOMY ELBOW W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24100,"CodeDescription":"ARTHROTOMY ELBOW W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24100,"CodeDescription":"ARTHROTOMY ELBOW W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24100,"CodeDescription":"ARTHROTOMY ELBOW W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24100,"CodeDescription":"ARTHROTOMY ELBOW W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24101,"CodeDescription":"ARTHRT ELBOW W\/JNT EXPL W\/WOBX W\/WORMVL LOOSE\/FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24102,"CodeDescription":"ARTHROTOMY ELBOW W\/SYNOVECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24105,"CodeDescription":"EXCISION OLECRANON BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24110,"CodeDescription":"EXCISION\/CURTG BONE CYST\/BENIGN TUMOR HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24115,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUMOR HUMERUS W\/AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24116,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUM HUMERUS W\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24120,"CodeDescription":"EXC\/CURTG BONE CYST\/BENIGN TUMOR H\/N RDS\/OLECRN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24125,"CodeDescription":"EXC\/CURTG BONE CST\/B9 TUM H\/N RDS\/OLECRN W\/AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24126,"CodeDescription":"EXC\/CURTG BONE CST\/B9 TUM H\/N RDS\/OLECRN W\/ALGRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24130,"CodeDescription":"EXCISION RADIAL HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24134,"CodeDescription":"SEQUESTRECTOMY SHAFT\/DISTAL HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24136,"CodeDescription":"SEQUESTRECTOMY RADIAL HEAD OR NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24138,"CodeDescription":"SEQUESTRECTOMY OLECRANON PROCESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24140,"CodeDescription":"PARTIAL EXCISION BONE HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24145,"CodeDescription":"PARTIAL EXCISION BONE RADIAL HEAD\/NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24147,"CodeDescription":"PARTIAL EXCISION BONE OLECRANON PROCESS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24149,"CodeDescription":"RAD RESCJ CAPSL TISS&HTRTPC BONE ELBW CONTRCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24150,"CodeDescription":"RADICAL RESECTION TUMOR SHAFT\/DISTAL HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24152,"CodeDescription":"RADICAL RESECTION TUMOR RADIAL HEAD\/NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24155,"CodeDescription":"RESECTION ELBOW JOINT ARTHRECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24160,"CodeDescription":"PROSTHESIS REMOVAL HUMERAL AND ULNAR COMPONENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24164,"CodeDescription":"PROSTHESIS REMOVAL RADIAL HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24200,"CodeDescription":"RMVL FOREIGN BODY UPPER ARM\/ELBOW SUBCUTANEOUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24201,"CodeDescription":"REMOVAL FOREIGN BODY UPPER ARM\/ELBOW DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24220,"CodeDescription":"INJECTION ELBOW ARTHROGRAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24300,"CodeDescription":"MANIPULATION ELBOW UNDER ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24301,"CodeDescription":"MUSCLE\/TENDON TRANSFER UPPER ARM\/ELBOW SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24305,"CodeDescription":"TENDON LENGTHENING UPPER ARM\/ELBOW EA TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24310,"CodeDescription":"TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24320,"CodeDescription":"TENOPLASTY ELBOW TO SHOULDER SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24330,"CodeDescription":"FLEXOR-PLASTY ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24331,"CodeDescription":"FLEXOR-PLASTY ELBOW W\/EXTENSOR ADVANCEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24332,"CodeDescription":"TENOLYSIS TRICEPS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24340,"CodeDescription":"TENODESIS BICEPS TENDON ELBOW SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24341,"CodeDescription":"REPAIR TENDON\/MUSCLE UPPER ARM\/ELBOW EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24342,"CodeDescription":"RINSJ RPTD BICEPS\/TRICEPS TDN DSTL W\/WO TDN GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24343,"CodeDescription":"REPAIR LATERAL COLLATERAL LIGAMENT ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24344,"CodeDescription":"RCNSTJ LAT COLTRL LIGM ELBOW W\/TENDON GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24345,"CodeDescription":"REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24346,"CodeDescription":"RCNSTJ MEDIAL COLTRL LIGM ELBW W\/TDN GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24357,"CodeDescription":"TENOTOMY ELBOW LATERAL\/MEDIAL PERCUTANEOUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24358,"CodeDescription":"TNOT ELBOW LATERAL\/MEDIAL DEBRIDE OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24359,"CodeDescription":"TNOT ELBOW LATERAL\/MEDIAL DEBRIDE OPEN TDN RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24360,"CodeDescription":"ARTHROPLASTY ELBOW W\/MEMBRANE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24361,"CodeDescription":"ARTHROPLASTY ELBOW W\/DISTAL HUMRL PROSTC RPLCMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24362,"CodeDescription":"ARTHRP ELBOW W\/IMPLT&FSCA LATA LIGAMENT RCNSTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24363,"CodeDescription":"ARTHRP ELBOW W\/DISTAL HUM&PROX UR PROSTC RPLCM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24365,"CodeDescription":"ARTHROPLASTY RADIAL HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24366,"CodeDescription":"ARTHROPLASTY RADIAL HEAD W\/IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24370,"CodeDescription":"REVIS ELBOW ARTHRPLSTY HUMERAL\/ULNA COMPNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24371,"CodeDescription":"REVIS ELBOW ARTHRPLSTY HUMERAL&ULNA COMPNT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24400,"CodeDescription":"OSTEOTOMY HUMERUS W\/WO INTERNAL FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24410,"CodeDescription":"MLT OSTEOT W\/RELIGNMT IMED ROD HUMERAL SHAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24420,"CodeDescription":"OSTEOPLASTY HUMERUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24430,"CodeDescription":"REPAIR NON\/MALUNION HUMERUS W\/O GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24435,"CodeDescription":"REPAIR NON\/MALUNION HUMERUS W\/ILIAC\/OTH AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24470,"CodeDescription":"HEMIEPIPHYSEAL ARREST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24495,"CodeDescription":"DECOMPRESSION FASCT F\/ARM W\/BRACH ART EXPL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24498,"CodeDescription":"PROPH TX W\/WO METHYLMETHACRYLATE HUMERAL SHAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24500,"CodeDescription":"CLSD TX HUMERAL SHAFT FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24505,"CodeDescription":"CLTX HUMERAL SHFT FX W\/MANJ W\/WO SKELETAL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24515,"CodeDescription":"OPTX HUMERAL SHFT FX W\/PLATE\/SCREWS W\/WOCERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24515,"CodeDescription":"OPTX HUMERAL SHFT FX W\/PLATE\/SCREWS W\/WOCERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24515,"CodeDescription":"OPTX HUMERAL SHFT FX W\/PLATE\/SCREWS W\/WOCERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24515,"CodeDescription":"OPTX HUMERAL SHFT FX W\/PLATE\/SCREWS W\/WOCERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24515,"CodeDescription":"OPTX HUMERAL SHFT FX W\/PLATE\/SCREWS W\/WOCERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24516,"CodeDescription":"TX HUMRAL SHAFT FX W\/INSJ IMED IMPLT W\/W CERCLGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24516,"CodeDescription":"TX HUMRAL SHAFT FX W\/INSJ IMED IMPLT W\/W CERCLGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24516,"CodeDescription":"TX HUMRAL SHAFT FX W\/INSJ IMED IMPLT W\/W CERCLGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24516,"CodeDescription":"TX HUMRAL SHAFT FX W\/INSJ IMED IMPLT W\/W CERCLGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24516,"CodeDescription":"TX HUMRAL SHAFT FX W\/INSJ IMED IMPLT W\/W CERCLGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24530,"CodeDescription":"CLTX SPRCNDYLR\/TRANSCNDYLR HUMERAL FX W\/WO MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24535,"CodeDescription":"CLTX SPRCNDYLR\/TRANSCNDYLR HUMERAL FX W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24538,"CodeDescription":"PRQ SKEL FIXJ SPRCNDYLR\/TRANSCNDYLR HUMERAL FX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24545,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/O XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24545,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/O XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24545,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/O XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24545,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/O XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24545,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/O XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24546,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24546,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24546,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24546,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24546,"CodeDescription":"OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W\/XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24560,"CodeDescription":"CLTX HUMERAL EPICONDYLAR FX MEDIAL\/LAT W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24565,"CodeDescription":"CLTX HUMERAL EPICONDYLAR FX MEDIAL\/LAT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24566,"CodeDescription":"PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL\/LAT MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24575,"CodeDescription":"OPEN TX HUMERAL EPICONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24575,"CodeDescription":"OPEN TX HUMERAL EPICONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24575,"CodeDescription":"OPEN TX HUMERAL EPICONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24575,"CodeDescription":"OPEN TX HUMERAL EPICONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24575,"CodeDescription":"OPEN TX HUMERAL EPICONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24576,"CodeDescription":"CLTX HUMERAL CONDYLAR FX MEDIAL\/LAT W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24577,"CodeDescription":"CLTX HUMERAL CONDYLAR FX MEDIAL\/LATERAL W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24579,"CodeDescription":"OPEN TREATMENT HUMERAL CONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24579,"CodeDescription":"OPEN TREATMENT HUMERAL CONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24579,"CodeDescription":"OPEN TREATMENT HUMERAL CONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24579,"CodeDescription":"OPEN TREATMENT HUMERAL CONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24579,"CodeDescription":"OPEN TREATMENT HUMERAL CONDYLAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24582,"CodeDescription":"PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL\/LAT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24582,"CodeDescription":"PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL\/LAT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24582,"CodeDescription":"PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL\/LAT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24582,"CodeDescription":"PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL\/LAT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24582,"CodeDescription":"PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL\/LAT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24586,"CodeDescription":"OPTX PERIARTICULAR FRACTURE &\/DISLOCATION ELBO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24586,"CodeDescription":"OPTX PERIARTICULAR FRACTURE &\/DISLOCATION ELBO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24586,"CodeDescription":"OPTX PERIARTICULAR FRACTURE &\/DISLOCATION ELBO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24586,"CodeDescription":"OPTX PERIARTICULAR FRACTURE &\/DISLOCATION ELBO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24586,"CodeDescription":"OPTX PERIARTICULAR FRACTURE &\/DISLOCATION ELBO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24587,"CodeDescription":"OPTX PRIARTICULAR FX&\/DISLC ELBW W\/IMPLT ARTHR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24587,"CodeDescription":"OPTX PRIARTICULAR FX&\/DISLC ELBW W\/IMPLT ARTHR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24587,"CodeDescription":"OPTX PRIARTICULAR FX&\/DISLC ELBW W\/IMPLT ARTHR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24587,"CodeDescription":"OPTX PRIARTICULAR FX&\/DISLC ELBW W\/IMPLT ARTHR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24587,"CodeDescription":"OPTX PRIARTICULAR FX&\/DISLC ELBW W\/IMPLT ARTHR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24600,"CodeDescription":"TREATMENT CLOSED ELBOW DISLOCATION W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24605,"CodeDescription":"TREATMENT CLOSED ELBOW DISLOCATION REQ ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24615,"CodeDescription":"OPEN TX ACUTE\/CHRONIC ELBOW DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24615,"CodeDescription":"OPEN TX ACUTE\/CHRONIC ELBOW DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24615,"CodeDescription":"OPEN TX ACUTE\/CHRONIC ELBOW DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24615,"CodeDescription":"OPEN TX ACUTE\/CHRONIC ELBOW DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24615,"CodeDescription":"OPEN TX ACUTE\/CHRONIC ELBOW DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24620,"CodeDescription":"CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24635,"CodeDescription":"OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24635,"CodeDescription":"OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24635,"CodeDescription":"OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24635,"CodeDescription":"OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24635,"CodeDescription":"OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":24640,"CodeDescription":"CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":24650,"CodeDescription":"CLOSED TX RADIAL HEAD\/NECK FX W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24655,"CodeDescription":"CLOSED TX RADIAL HEAD\/NECK FX W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24665,"CodeDescription":"OPEN TX RADIAL HEAD\/NECK FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24666,"CodeDescription":"OPEN TX RADIAL HEAD\/NECK FRACTURE PROSTHETIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24670,"CodeDescription":"CLOSED TX ULNAR FRACTURE PROXIMAL END W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24675,"CodeDescription":"CLOSED TX ULNAR FRACTURE PROXIMAL END W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24685,"CodeDescription":"OPEN TREATMENT ULNAR FRACTURE PROXIMAL END","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24800,"CodeDescription":"ARTHRODESIS ELBOW JOINT LOCAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24802,"CodeDescription":"ARTHRODESIS ELBOW JOINT W\/AUTOGENOUS GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24900,"CodeDescription":"AMPUTATION ARM THRU HUMERUS W\/PRIMARY CLOSURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24920,"CodeDescription":"AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24925,"CodeDescription":"AMP ARM THRU HUMERUS SECONDARY CLSR\/SCAR REVJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24930,"CodeDescription":"AMPUTATION ARM THRU HUMERUS RE-AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24931,"CodeDescription":"AMPUTATION ARM THRU HUMERUS W\/IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24935,"CodeDescription":"STUMP ELONGATION UPPER EXTREMITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24940,"CodeDescription":"CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":24999,"CodeDescription":"UNLISTED PROCEDURE HUMERUS\/ELBOW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25000,"CodeDescription":"INCISION EXTENSOR TENDON SHEATH WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25001,"CodeDescription":"INCISION FLEXOR TENDON SHEATH WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25020,"CodeDescription":"DCMPRN FASCT F\/ARM&WRST FLXR\/XTNSR W\/O DBRDMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25023,"CodeDescription":"DCMPRN FASCT F\/ARM&\/WRST FLXR\/XTNSR W\/DBRDMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25024,"CodeDescription":"DCMPRN FASCT F\/ARM&\/WRST FLXR&XTNSR W\/O DB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25025,"CodeDescription":"DCMPRN FASCT F\/ARM&\/WRST FLXR&XTNSR DBRDMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25028,"CodeDescription":"I&D FOREARM&\/WRIST DEEP ABSCESS\/HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25031,"CodeDescription":"INCISION & DRAINAGE FOREARM&\/WRIST BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25035,"CodeDescription":"INCISION DEEP BONE CORTEX FOREARM&\/WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25040,"CodeDescription":"ARTHRT RDCRPL\/MIDCARPL JT W\/EXPL DRG\/RMVL FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25065,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25065,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25065,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25065,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25065,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25066,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25066,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25066,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25066,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25066,"CodeDescription":"BIOPSY SOFT TISSUE FOREARM&\/WRIST DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25071,"CodeDescription":"EXC TUMOR SOFT TISS FOREARM AND\/WRIST SUBQ 3CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25073,"CodeDescription":"EXC TUMOR SFT TISS FOREARM&\/WRIST SUBFASC 3CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25075,"CodeDescription":"EXC TUMOR SOFT TISSUE FOREARM &\/WRIST SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25076,"CodeDescription":"EXC TUMOR SOFT TISS FOREARM&\/WRIST SUBFASC  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25077,"CodeDescription":"RAD RESECT TUMOR SOFT TISS FOREARM&\/WRIST  LT 3 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25078,"CodeDescription":"RAD RESCJ TUM SOFT TISSUE FOREARM&\/WRIST 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25085,"CodeDescription":"CAPSULOTOMY WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25100,"CodeDescription":"ARTHROTOMY WRIST JOINT WITH BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25100,"CodeDescription":"ARTHROTOMY WRIST JOINT WITH BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25100,"CodeDescription":"ARTHROTOMY WRIST JOINT WITH BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25100,"CodeDescription":"ARTHROTOMY WRIST JOINT WITH BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25100,"CodeDescription":"ARTHROTOMY WRIST JOINT WITH BIOPSY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":25101,"CodeDescription":"ARTHRT WRST W\/JT EXPL W\/WO BX W\/WO RMVL LOOSE\/FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25105,"CodeDescription":"ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25107,"CodeDescription":"ARTHROTOMY DSTL RADIOULNAR JOINT RPR CARTILAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25109,"CodeDescription":"EXC TENDON FOREARM&\/WRIST FLEXOR\/EXTENSOR EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25110,"CodeDescription":"EXCISION LESION TENDON SHEATH FOREARM&\/WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25111,"CodeDescription":"EXCISION GANGLION WRIST DORSAL\/VOLAR PRIMARY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25112,"CodeDescription":"EXCISION GANGLION WRIST DORSAL\/VOLAR RECURRENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25115,"CodeDescription":"RAD EXC BURSA SYNVA WRST\/F\/ARM TDN SHTHS FLXRS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25116,"CodeDescription":"RAD EXC BURSA SYNVA WRST\/F\/ARM TDN SHTHS XTNSRS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25118,"CodeDescription":"SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25119,"CodeDescription":"SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25120,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR RADIUS\/ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25125,"CodeDescription":"EXC\/CURTG CYST\/TUMOR RADIUS\/ULNA W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25126,"CodeDescription":"EXC\/CURTG CYST\/TUMOR RADIUS\/ULNA W\/ALLOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25130,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR CARPAL BONES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25135,"CodeDescription":"EXC\/CURTG CYST\/TUMOR CARPAL BONES W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25136,"CodeDescription":"EXC\/CURTG CYST\/TUMOR CARPAL BONES W\/ALLOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25145,"CodeDescription":"SEQUESTRECTOMY FOREARM &\/WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25150,"CodeDescription":"PARTIAL EXCISION BONE ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25151,"CodeDescription":"PARTIAL EXCISION BONE RADIUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25170,"CodeDescription":"RADICAL RESECTION TUMOR RADIUS OR ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25210,"CodeDescription":"CARPECTOMY 1 BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25215,"CodeDescription":"CARPECTOMY ALL BONES PROXIMAL ROW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25230,"CodeDescription":"RADICAL STYLOIDECTOMY SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25240,"CodeDescription":"EXCISION DISTAL ULNA PARTIAL\/COMPLETE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25246,"CodeDescription":"INJECTION WRIST ARTHROGRAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25248,"CodeDescription":"EXPL W\/REMOVAL DEEP FOREIGN BODY FOREARM\/WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25250,"CodeDescription":"REMOVAL WRIST PROSTHESIS SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25251,"CodeDescription":"REMOVAL WRIST PROSTH COMPLICATED W\/TOTAL WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25259,"CodeDescription":"MANIPULATION WRIST UNDER ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25260,"CodeDescription":"RPR TDN\/MUSC FLXR F\/ARM&\/WRST PRIM 1 EA TDN\/MU","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25263,"CodeDescription":"RPR TDN\/MUSC FLXR F\/ARM&\/WRIST SEC 1 EA TDN\/MUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25265,"CodeDescription":"RPR TDN\/MUSC FLXR F\/ARM&\/WRISTSEC FR GRF EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25270,"CodeDescription":"RPR TDN\/MUSC XTNSR F\/ARM&\/WRIST PRIM 1 EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25272,"CodeDescription":"RPR TDN\/MUSC XTNSR F\/ARM&\/WRIST SEC 1 EA TDN\/MU","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25274,"CodeDescription":"RPR TDN\/MUSC XTNSR F\/ARM&\/WRST SEC FR GRF EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25275,"CodeDescription":"RPR TENDON SHEATH EXTENSOR F\/ARM&\/WRIST W\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25280,"CodeDescription":"LNGTH\/SHRT FLXR\/XTNSR TDN F\/ARM&\/WRIST 1 EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25290,"CodeDescription":"TNOT FLXR\/XTNSR TENDON FOREARM&\/WRIST 1 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25295,"CodeDescription":"TNOLS FLXR\/XTNSR TENDON FOREARM&\/WRIST 1 EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25300,"CodeDescription":"TENODESIS WRIST FLEXORS FINGERS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25301,"CodeDescription":"TENODESIS WRIST EXTENSORS FINGERS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25315,"CodeDescription":"FLEXOR ORIGIN SLIDE FOREARM &\/WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25316,"CodeDescription":"FLEXOR ORIGIN SLIDE F\/ARM&\/WRST TENDON TRANSFE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25320,"CodeDescription":"CAPSL-RHPHY\/RCNSTJ WRST OPN CARPL INS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25332,"CodeDescription":"ARTHRP WRST W\/WO INTERPOS W\/WO XTRNL\/INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25335,"CodeDescription":"CENTRALIZATION WRST ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25337,"CodeDescription":"RCNSTJ STABLJ DSTL U\/DSTL JT 2 SOFT TISS STABLJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25350,"CodeDescription":"OSTEOTOMY RADIUS DISTAL THIRD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25355,"CodeDescription":"OSTEOTOMY RADIUS MIDDLE\/PROXIMAL THIRD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25360,"CodeDescription":"OSTEOTOMY ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25365,"CodeDescription":"OSTEOTOMY RADIUS & ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25370,"CodeDescription":"MLT OSTEOTOMIES W\/RELIGNMT IMED ROD RADIUS\/ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25375,"CodeDescription":"MLT OSTEOTOMIES W\/RELIGNMT IMED ROD RADIUS&ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25390,"CodeDescription":"OSTEOPLASTY RADIUS\/ULNA SHORTENING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25391,"CodeDescription":"OSTEOPLASTY RADIUS\/ULNA LENGTHENING W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25392,"CodeDescription":"OSTEOPLASTY RADIUS & ULNA SHORTENING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25393,"CodeDescription":"OSTEOPLASTY RADIUS&ULNA LENGTHENING W\/AUTOGRAF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25394,"CodeDescription":"OSTEOPLASTY CARPAL BONE SHORTENING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25400,"CodeDescription":"RPR NONUNION\/MALUNION RADIUS\/ULNA W\/O AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25405,"CodeDescription":"RPR NONUNION\/MALUNION RADIUS\/ULNA W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25415,"CodeDescription":"RPR NONUNION\/MALUNION RADIUS&ULNA W\/O AUTOGRAF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25420,"CodeDescription":"RPR NONUNION\/MALUNION RADIUS&ULNA W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25425,"CodeDescription":"REPAIR DEFECT W\/AUTOGRAFT RADIUS\/ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25426,"CodeDescription":"REPAIR DEFECT W\/AUTOGRAFT RADIUS&ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25430,"CodeDescription":"INSERTION VASCULAR PEDICLE CARPAL BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25431,"CodeDescription":"REPAIR NONUNION CARPAL BONE EACH BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25440,"CodeDescription":"RPR NONUNION SCAPHOID CARPAL BNE W\/WO RDL STYLEC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25441,"CodeDescription":"ARTHROPLASTY W\/PROSTHETIC RPLCMT DISTAL RADIUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25442,"CodeDescription":"ARTHROPLASTY W\/PROSTHETIC RPLCMT DISTAL ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25443,"CodeDescription":"ARTHROPLASTY W\/PROSTHETIC RPLCMT SCAPHOID CARPAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25444,"CodeDescription":"ARTHROPLASTY W\/PROSTHETIC REPLACEMENT LUNATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25445,"CodeDescription":"ARTHROPLASTY W\/PROSTHETIC REPLACEMENT TRAPEZIUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25446,"CodeDescription":"ARTHRP W\/PROSTC RPLCMT DSTL RDS&PRTL\/CARPUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25447,"CodeDescription":"ARTHRP INTERPOS INTERCARPAL\/METACARPAL JOINTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25449,"CodeDescription":"REVJ ARTHRP W\/REMOVAL IMPLANT WRIST JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25450,"CodeDescription":"EPIPHYSL ARRST EPIPHYSIOD\/STAPLING DSTL RDS\/U","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25455,"CodeDescription":"EPIPHYSL ARRST EPIPHYSIOD\/STAPLING DSTL RDS&ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25490,"CodeDescription":"PROPH TX N\/P\/PLTWR W\/WO METHYLACRYLATE RADIUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25491,"CodeDescription":"PROPH TX N\/P\/PLTWR W\/WO METHYLMETHACRYLATE ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25492,"CodeDescription":"PROPH TX N\/P\/PLTWR W\/WO METHYLMECRYLATE RAD&UL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25500,"CodeDescription":"CLOSED TX RADIAL SHAFT FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25505,"CodeDescription":"CLOSED TX RADIAL SHAFT FRACTURE W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25515,"CodeDescription":"OPEN TREATMENT RADIAL SHAFT FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25520,"CodeDescription":"CLTX RDL SHFT FX&CLTX DISLC DSTL RAD\/ULN JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25525,"CodeDescription":"OPEN RDL SHAFT FX CLOSED RAD\/ULN JT DISLOCATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25526,"CodeDescription":"OPEN RDL SHAFT FX OPEN RAD\/ULN JT DISLOCATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25530,"CodeDescription":"CLOSED TX ULNAR SHAFT FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25535,"CodeDescription":"CLOSED TX ULNAR SHAFT FRACTURE W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25545,"CodeDescription":"OPEN TREATMENT OF ULNAR SHAFT FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25560,"CodeDescription":"CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W\/O MAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25565,"CodeDescription":"CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25574,"CodeDescription":"OPEN TX RADIAL&ULNAR SHAFT FX W\/FIXJ RADIUS\/ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25575,"CodeDescription":"OPEN TX RADIAL&ULNAR SHAFT FX W\/FIXJ RADIUS&ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25600,"CodeDescription":"CLTX DSTL RADIAL FX\/EPIPHYSL SEP W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25605,"CodeDescription":"CLTX DSTL RDL FX\/EPIPHYSL SEP W\/MANJ WHEN PERF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25606,"CodeDescription":"PERQ SKEL FIXJ DISTAL RADIAL FX\/EPIPHYSL SEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25607,"CodeDescription":"OPTX DSTL RADL X-ARTIC FX\/EPIPHYSL SEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25608,"CodeDescription":"OPTX DSTL RADL I-ARTIC FX\/EPIPHYSL SEP 2 FRAG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25609,"CodeDescription":"OPTX DSTL RADL I-ARTIC FX\/EPIPHYSL SEP 3 FRAG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25622,"CodeDescription":"CLOSED TX CARPAL SCAPHOID FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25624,"CodeDescription":"CLOSED TX CARPAL SCAPHOID FRACTURE W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25628,"CodeDescription":"OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25630,"CodeDescription":"CLTX CARPAL BONE FX W\/O MANJ EACH BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25635,"CodeDescription":"CLTX CARPAL BONE FX W\/MANJ EACH BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25645,"CodeDescription":"OPEN TX CARPAL BONE FRACTURE OTH\/THN SCAPHOID EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25650,"CodeDescription":"CLOSED TREATMENT ULNAR STYLOID FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25651,"CodeDescription":"PRQ SKELETAL FIXATION ULNAR STYLOID FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25652,"CodeDescription":"OPEN TREATMENT ULNAR STYLOID FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25660,"CodeDescription":"CLTX RDCRPL\/INTERCARPL DISLC 1 GE BONES W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25670,"CodeDescription":"OPEN TX RADIOCARPAL\/INTERCARPAL DISLC 1 GE BONES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25671,"CodeDescription":"PRQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25675,"CodeDescription":"CLOSED TX DISTAL RADIOULNAR DISLOCATION W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25676,"CodeDescription":"OPEN TX DISTAL RADIOULNAR DISLC ACUTE\/CHRONIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25680,"CodeDescription":"CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25685,"CodeDescription":"OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25690,"CodeDescription":"CLOSED TX LUNATE DISLOCATION W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25695,"CodeDescription":"OPEN TREATMENT LUNATE DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25800,"CodeDescription":"ARTHRODESIS WRIST COMPLETE W\/O BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25805,"CodeDescription":"ARTHRODESIS WRIST W\/SLIDING GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25810,"CodeDescription":"ARTHRODESIS WRIST W\/ILIAC\/OTHER AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25820,"CodeDescription":"ARTHRODESIS WRIST LIMITED W\/O BONE GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25825,"CodeDescription":"ARTHRODESIS WRIST LIMITED W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25830,"CodeDescription":"ARTHRD DSTL RAD\/ULN JT SGMTL RSCJ ULNA W\/WO BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25900,"CodeDescription":"AMPUTATION FOREARM THROUGH RADIUS & ULNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25905,"CodeDescription":"AMP FOREARM THRU RADIUS & ULNA OPEN CIRCULAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25907,"CodeDescription":"AMP F\/ARM THRU RADIUS&ULNA SEC CLOSURE\/SCAR RE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25909,"CodeDescription":"AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25915,"CodeDescription":"KRUKENBERG PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25920,"CodeDescription":"DISARTICULATION THROUGH WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25922,"CodeDescription":"DISARTICULATION THRU WRIST SEC CLOSURE\/SCAR REVJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25924,"CodeDescription":"DISARTICULATION THRU WRIST RE-AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25927,"CodeDescription":"TRANSMETACARPAL AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25929,"CodeDescription":"TRANSMETACARPAL AMPUTATION SEC CLOSURE\/SCAR REVJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25931,"CodeDescription":"TRANSMETACARPAL AMPUTATION RE-AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":25999,"CodeDescription":"UNLISTED PROCEDURE FOREARM\/WRIST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26010,"CodeDescription":"DRAINAGE FINGER ABSCESS SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26011,"CodeDescription":"DRAINAGE FINGER ABSCESS COMPLICATED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26020,"CodeDescription":"DRAINAGE TENDON SHEATH DIGIT&\/PALM EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26025,"CodeDescription":"DRAINAGE OF PALMAR BURSA SINGLE BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26030,"CodeDescription":"DRAINAGE OF PALMAR BURSA MULTIPLE BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26034,"CodeDescription":"INCISION BONE CORTEX HAND\/FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26035,"CodeDescription":"DECOMPRESSION FINGERS&\/HAND INJECTION INJURY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26037,"CodeDescription":"DECOMPRESSIVE FASCIOTOMY HAND","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26040,"CodeDescription":"FASCIOTOMY PALMAR PERCUTANEOUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26045,"CodeDescription":"FASCIOTOMY PALMAR OPEN PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26055,"CodeDescription":"TENDON SHEATH INCISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26060,"CodeDescription":"TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26070,"CodeDescription":"ARTHRT EXPL DRG\/RMVL LOOSE\/FB CARP\/MTCRPL JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26075,"CodeDescription":"ARTHRT EXPL DRG\/RMVL LOOSE\/FB MTCARPHLNGL JT EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26080,"CodeDescription":"ARTHRT EXPL DRG\/RMVL LOOSE\/FB IPHAL JT EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26100,"CodeDescription":"ARTHROTOMY BIOPSY CARP\/MTCRPL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26100,"CodeDescription":"ARTHROTOMY BIOPSY CARP\/MTCRPL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26100,"CodeDescription":"ARTHROTOMY BIOPSY CARP\/MTCRPL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26100,"CodeDescription":"ARTHROTOMY BIOPSY CARP\/MTCRPL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26100,"CodeDescription":"ARTHROTOMY BIOPSY CARP\/MTCRPL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26105,"CodeDescription":"ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26105,"CodeDescription":"ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26105,"CodeDescription":"ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26105,"CodeDescription":"ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26105,"CodeDescription":"ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26110,"CodeDescription":"ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26110,"CodeDescription":"ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26110,"CodeDescription":"ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26110,"CodeDescription":"ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26110,"CodeDescription":"ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":26111,"CodeDescription":"EX TUM\/VASC MALF SFT TISS HAND\/FNGR SUBQ 1.5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26113,"CodeDescription":"EX TUM\/VASC MAL SFT TIS HAND\/FNGR SUBFSC 1.5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26115,"CodeDescription":"EXC TUM\/VASC MAL SFT TISS HAND\/FNGR SUBQ  LT 1.5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26116,"CodeDescription":"EXC TUM\/VAS MAL SFT TIS HAND\/FNGR SUBFASC LT 1.5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26117,"CodeDescription":"RAD RESECT TUMOR SOFT TISSUE HAND\/FINGER  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26118,"CodeDescription":"RAD RESCJ TUM SOFT TISSUE HAND\/FINGER 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26121,"CodeDescription":"FASCT PALM W\/WO Z-PLASTY TISSUE REARGMT\/SKN GRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26123,"CodeDescription":"FASCT PRTL PALMAR 1 DGT PROX IPHAL JT W\/WO RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26125,"CodeDescription":"FASCT PRTL PALMR ADDL DGT PROX IPHAL JT W\/WO RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26130,"CodeDescription":"SYNOVECTOMY CARPOMETACARPAL JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26135,"CodeDescription":"SYNVCT MTCARPHLNGL JT W\/INTRNSC RLS&XTNSR HOOD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26140,"CodeDescription":"SYNVCT PROX IPHAL JT W\/XTNSR RCNSTJ EA IPHAL JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26145,"CodeDescription":"SYNVCT TDN SHTH RAD FLXR TDN PALM&\/FNGR EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26160,"CodeDescription":"EXC LESION TDN SHTH\/JT CAPSL HAND\/FNGR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26170,"CodeDescription":"EXCISION TENDON PALM FLEXOR\/EXTENSOR SINGLE EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26180,"CodeDescription":"EXCISION TENDON FINGER FLEXOR\/EXTENSOR EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26185,"CodeDescription":"SESAMOIDECTOMY THUMB\/FINGER SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26200,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR METACARPAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26205,"CodeDescription":"EXC\/CURETTAGE CYST\/TUMOR METACARPAL W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26210,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR PHALANX FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26215,"CodeDescription":"EXC\/CURETTAGE CYST\/TUMOR PHALANX FINGER W\/AGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26230,"CodeDescription":"PARTIAL EXCISION BONE METACARPAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26235,"CodeDescription":"PARTIAL EXCISION PROXIMAL\/MIDDLE PHALANX FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26236,"CodeDescription":"PARTIAL EXCISION DISTAL PHALANX FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26250,"CodeDescription":"RADICAL RESECTION TUMOR METACARPAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26260,"CodeDescription":"RAD RESECTION TUMOR PROX\/MIDDLE PHALANX FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26262,"CodeDescription":"RADICAL RESECTION TUMOR DISTAL PHALANX FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26320,"CodeDescription":"REMOVAL IMPLANT FROM FINGER\/HAND","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26340,"CodeDescription":"MANIPULATION FINGER JOINT UNDER ANES EACH JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26341,"CodeDescription":"MANIPLATN PALAR FASCIAL CRD POST INJ SINGLE CORD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26350,"CodeDescription":"RPR\/ADVMNT FLXR TDN N\/Z\/2 W\/O FR GRAFT EA TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26352,"CodeDescription":"RPR\/ADVMNT FLXR TDN N\/Z\/2 W\/FR GRAFT EA TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26356,"CodeDescription":"RPR\/ADVMNT FLXR TDN ZONE 2 W\/O FR GRFT EA TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26357,"CodeDescription":"RPR\/ADVMNT FLXR TDN ZONE 2 W\/O FR GRFT EA TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26358,"CodeDescription":"RPR\/ADVMNT FLXR TDN ZONE 2 W\/FR GRAFT EA TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26370,"CodeDescription":"RPR\/ADVMNT TDN W\/NTC SUPFCIS TDN PRIM EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26372,"CodeDescription":"RPR\/ADVMNT TDN W\/NTC SUPFCIS TDN W\/FREE GRAFT EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26373,"CodeDescription":"RPR\/ADVMNT TDN W\/NTC SUPFCIS TDN W\/O FREE GRF EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26390,"CodeDescription":"EXC FLXR TDN W\/IMPLTJ SYNTH ROD DLYD TDN GRF H\/F","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26392,"CodeDescription":"RMVL SYNTH ROD & INSJ FLXR TDN GRF H\/F EA ROD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26410,"CodeDescription":"REPAIR EXTENSOR TENDON HAND W\/O GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26412,"CodeDescription":"REPAIR EXTENSOR TENDON HAND W\/GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26415,"CodeDescription":"EXC XTNSR TDN W\/IMPLTJ SYNTH ROD DLYD GRF H\/F EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26416,"CodeDescription":"RMVL SYNTH ROD & INSJ XTNSR TDN GRF H\/F EA ROD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26418,"CodeDescription":"REPAIR EXTENSOR TENDON FINGER W\/O GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26420,"CodeDescription":"REPAIR EXTENSOR TENDON FINGER W\/GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26426,"CodeDescription":"RPR XTNSR TDN CNTRL SLIP TISS W\/LAT BAND EA FNGR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26428,"CodeDescription":"RPR XTNSR TDN CNTRL SLIP SEC W\/FR GRFT EA FINGER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26432,"CodeDescription":"CLTX DSTL XTNSR TDN INSJ W\/WO PERCUTAN PINNING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26433,"CodeDescription":"REPAIR EXTENSOR TENDON DISTAL INSERTION W\/O GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26434,"CodeDescription":"REPAIR EXTENSOR TENDON DISTAL INSERTION W\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26437,"CodeDescription":"REALIGNMENT EXTENSOR TENDON HAND EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26440,"CodeDescription":"TENOLYSIS FLEXOR TENDON PALM\/FINGER EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26442,"CodeDescription":"TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDO","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26445,"CodeDescription":"TENOLYSIS EXTENSOR TENDON HAND\/FINGER EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26449,"CodeDescription":"TENOLYSIS CPLX XTNSR TENDON FINGER W\/FOREARM EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26450,"CodeDescription":"TENOTOMY FLEXOR PALM OPEN EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26455,"CodeDescription":"TENOTOMY FLEXOR FINGER OPEN EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26460,"CodeDescription":"TENOTOMY EXTENSOR HAND\/FINGER OPEN EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26471,"CodeDescription":"TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26474,"CodeDescription":"TENODESIS DISTAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26476,"CodeDescription":"LENGTHENING TENDON EXTENSOR HAND\/FINGER EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26477,"CodeDescription":"SHORTENING TENDON EXTENSOR HAND\/FINGER EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26478,"CodeDescription":"LENGTHENING TENDON FLEXOR HAND\/FINGER EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26479,"CodeDescription":"SHORTENING TENDON FLEXOR HAND\/FINGER EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26490,"CodeDescription":"OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26492,"CodeDescription":"OPPONENSPLASTY TDN TR W\/GRF EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26494,"CodeDescription":"OPPONENSPLASTY HYPOTHENAR MUSC TR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26496,"CodeDescription":"OPPONENSPLASTY OTHER METHODS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26497,"CodeDescription":"TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26498,"CodeDescription":"TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26499,"CodeDescription":"CORRECTION CLAW FINGER OTHER METHODS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26500,"CodeDescription":"RCNSTJ TENDON PULLEY EACH W\/LOCAL TISSUES SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26502,"CodeDescription":"RCNSTJ TDN PULLEY EA TDN W\/TDN\/FSCAL GRF SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26508,"CodeDescription":"RELEASE THENAR MUSCLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26510,"CodeDescription":"CROSS INTRINSIC TRANSFER EACH TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26516,"CodeDescription":"CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26517,"CodeDescription":"CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26518,"CodeDescription":"CAPSULODESIS MTCARPHLNGL JOINT 3\/4 DIGITS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26520,"CodeDescription":"CAPSULECTOMY\/CAPSULOTOMY MTCARPHLNGL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26525,"CodeDescription":"CAPSULECTOMY\/CAPSULOTOMY IPHAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26530,"CodeDescription":"ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26531,"CodeDescription":"ARTHRP MTCARPHLNGL JT W\/PROSTC IMPLT EA JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26535,"CodeDescription":"ARTHROPLASTY INTERPHALANGEAL JOINT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26536,"CodeDescription":"ARTHROPLASTY INTERPHALANGEAL JT W\/PROSTHETIC EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26540,"CodeDescription":"RPR COLTRL LIGM MTCARPHLNGL\/IPHAL JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26541,"CodeDescription":"RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W\/TDN\/FSCAL GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26542,"CodeDescription":"RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W\/LOCAL TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26545,"CodeDescription":"RCNSTJ COLTRL LIGM IPHAL JT 1 W\/GRF EA JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26546,"CodeDescription":"RPR NON-UNION MTCRPL\/PHALANX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26548,"CodeDescription":"RPR & RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26550,"CodeDescription":"POLLICIZATION DIGIT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26551,"CodeDescription":"TR TOE-TO-HAND W\/MVASC ANAST GRT TOE WRP\/ARND","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26553,"CodeDescription":"TR TOE-TO-HAND W\/MVASC ANAST OTH\/THN GRT TOE 1","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26554,"CodeDescription":"TR TOE-TO-HAND W\/MVASC ANAST OTH\/THN GRT TOE 2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26555,"CodeDescription":"TR FNGR AXH POS W\/O MVASC ANAST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26556,"CodeDescription":"TRANSFER FREE TOE JOINT W\/MVASC ANASTOMOSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26560,"CodeDescription":"REPAIR SYNDACTYLY EACH SPACE W\/SKIN FLAPS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26561,"CodeDescription":"REPAIR SYNDACTYLY EACH SPACE W\/SKIN FLAPS&GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26562,"CodeDescription":"REPAIR SYNDACTYLY EACH SPACE COMPLEX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26565,"CodeDescription":"OSTEOTOMY METACARPAL EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26567,"CodeDescription":"OSTEOTOMY PHALANX FINGER EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26568,"CodeDescription":"OSTEOPLASTY LENGTHENING METACARPAL\/PHALANX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26580,"CodeDescription":"REPAIR CLEFT HAND","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26587,"CodeDescription":"RCNSTJ POLYDACTYLOUS DIGIT SOFT TISSUE & BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26590,"CodeDescription":"REPAIR MACRODACTYLIA EACH DIGIT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26591,"CodeDescription":"REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26593,"CodeDescription":"RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26596,"CodeDescription":"EXC CONSTRICTING RING FNGR W\/MLT Z-PLASTIES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26600,"CodeDescription":"CLTX METACARPAL FX W\/O MANIPULATION EACH BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26605,"CodeDescription":"CLTX METACARPAL FX W\/MANIPULATION EACH BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26607,"CodeDescription":"CLTX METACARPAL FX W\/MANJ W\/XTRNL FIXJ EA BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26608,"CodeDescription":"PRQ SKELETAL FIXJ METACARPAL FX EACH BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26615,"CodeDescription":"OPEN TX METACARPAL FRACTURE SINGLE EA BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26641,"CodeDescription":"CLTX CARPO\/METACARPAL DISLOCATION THUMB W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26645,"CodeDescription":"CLTX CARPO\/METACARPAL FX DISLC THUMB W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26650,"CodeDescription":"PRQ SKELETAL FIX CARPO\/METACARPAL FX DISLC THUMB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26665,"CodeDescription":"OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26670,"CodeDescription":"CLTX CARPO\/METACARPL DISLC THMB MANJ EA W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26675,"CodeDescription":"CLTX CARPO\/MTCRPL DISLC THUMB MANJ EA JT W\/ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26676,"CodeDescription":"PRQ SKEL FIXJ CARPO\/MTCRPL DISLC THMB MANJ EA JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26685,"CodeDescription":"OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26686,"CodeDescription":"OPTX CARP\/MTCRPL DISLC THMB CPLX MLT\/DLYD RDCTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26700,"CodeDescription":"CLTX METACARPOPHALANGEAL DISLC W\/MANJ W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26705,"CodeDescription":"CLTX METACARPOPHALANGEAL DISLC W\/MANJ W\/ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26706,"CodeDescription":"PRQ SKEL FIXJ METACARPOPHALANGEAL DISLC W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26715,"CodeDescription":"OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26720,"CodeDescription":"CLTX PHLNGL FX PROX\/MIDDLE PX\/F\/T W\/O MANJ EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26725,"CodeDescription":"CLTX PHLNGL FX PROX\/MIDDLE PX\/F\/T W\/MANJ EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26727,"CodeDescription":"PRQ SKEL FIXJ PHLNGL SHFT FX PROX\/MIDDLE PX\/F\/T","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26735,"CodeDescription":"OPEN TX PHALANGEAL SHAFT FRACTURE PROX\/MIDDLE EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26740,"CodeDescription":"CLTX ARTCLR FX INVG MTCRPHLNGL\/IPHAL JT W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26742,"CodeDescription":"CLTX ARTCLR FX INVG MTCARPHLNGL\/IPHAL JT W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26746,"CodeDescription":"OPEN TX ARTICULAR FRACTURE MCP\/IP JOINT EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26750,"CodeDescription":"CLTX DSTL PHLNGL FX FNGR\/THMB W\/O MANJ EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26755,"CodeDescription":"CLTX DSTL PHLNGL FX FNGR\/THMB W\/MANJ EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26756,"CodeDescription":"PRQ SKEL FIXJ DSTL PHLNGL FX FNGR\/THMB EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26765,"CodeDescription":"OPEN TX DISTAL PHALANGEAL FRACTURE EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26770,"CodeDescription":"CLTX IPHAL JT DISLC W\/MANJ W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26775,"CodeDescription":"CLTX IPHAL JT DISLC W\/MANJ REQ ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26776,"CodeDescription":"PRQ SKEL FIXJ IPHAL JT DISLC W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26785,"CodeDescription":"OPEN TX INTERPHALANGEAL JOINT DISLOCATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26820,"CodeDescription":"FUSION OPPOSITION THUMB W\/AUTOGENOUS GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26841,"CodeDescription":"ARTHRD CARPO\/METACARPAL JT THUMB W\/WO INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26842,"CodeDescription":"ARTHRD CRP\/MTACRPL JT THMB W\/WO INT FIXJ W\/AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26843,"CodeDescription":"ARTHRD CARP\/MTCRPL JT DGT OTHER THAN THUMB EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26844,"CodeDescription":"ARTHRD CARP\/MTCRPL JT DGT OTH\/THN THMB W\/AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26850,"CodeDescription":"ARTHRODESIS METACARPOPHALANGEAL JT W\/WO INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26852,"CodeDescription":"ARTHRODESIS MTCRPL JT W\/WO INT FIXJ W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26860,"CodeDescription":"ARTHRODESIS INTERPHALANGEAL JT W\/WO INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26861,"CodeDescription":"ARTHRODESIS IPHAL JT W\/WO INT FIXJ EA IPHAL JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26862,"CodeDescription":"ARTHRODESIS IPHAL JT W\/WO INT FIXJ W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26863,"CodeDescription":"ARTHRODESIS IPHAL JT W\/WO INT FIXJ W\/AGRFT EA JT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26910,"CodeDescription":"AMP MTCRPL W\/FINGER\/THUMB W\/WO INTEROSS TRANSFER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26951,"CodeDescription":"AMP F\/TH 1\/2 JT\/PHALANX W\/NEURECT W\/DIR CLSR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26952,"CodeDescription":"AMP F\/TH 1\/2 JT\/PHALANX W\/NEURECT LOCAL FLAP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26989,"CodeDescription":"UNLISTED PROCEDURE HANDS\/FINGERS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26990,"CodeDescription":"I&D PELVIS\/HIP JT AREA DEEP ABSCESS\/HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26991,"CodeDescription":"I&D PELVIS\/HIP JOINT AREA INFECTED BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":26992,"CodeDescription":"INCISION BONE CORTEX PELVIS&\/HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27000,"CodeDescription":"TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27001,"CodeDescription":"TENOTOMY ADDUCTOR HIP OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27003,"CodeDescription":"TX ADDUXOR SUBQ OPN W\/OBTURATOR NEURECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27005,"CodeDescription":"TENOTOMY HIP FLEXOR OPEN SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27006,"CodeDescription":"TENOTOMY ABDUCTORS&\/EXTENSOR HIP OPEN SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27025,"CodeDescription":"FASCIOTOMY HIP\/THIGH ANY TYPE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27027,"CodeDescription":"DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27030,"CodeDescription":"ARTHROTOMY HIP W\/DRAINAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27033,"CodeDescription":"ARTHROTOMY HIP EXPLORATION\/REMOVAL FOREIGN BODY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27035,"CodeDescription":"DNRVTJ HIP JT INTRAPEL\/XTRPEL INTRA-ARTCLR BRNCH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27036,"CodeDescription":"CAPSLCTOMY\/CAPSUL HIP W\/RLS HIP FLXR MUSC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27040,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27040,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27040,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27040,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27040,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27041,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP DEEP\/SUBFSCAL\/IM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27041,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP DEEP\/SUBFSCAL\/IM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27041,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP DEEP\/SUBFSCAL\/IM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27041,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP DEEP\/SUBFSCAL\/IM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27041,"CodeDescription":"BIOPSY SOFT TISSUE PELVIS&HIP DEEP\/SUBFSCAL\/IM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27043,"CodeDescription":"EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27045,"CodeDescription":"EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27047,"CodeDescription":"EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27048,"CodeDescription":"EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27049,"CodeDescription":"RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP  LT 5 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27050,"CodeDescription":"ARTHROTOMY W\/BIOPSY SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27050,"CodeDescription":"ARTHROTOMY W\/BIOPSY SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27050,"CodeDescription":"ARTHROTOMY W\/BIOPSY SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27050,"CodeDescription":"ARTHROTOMY W\/BIOPSY SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27050,"CodeDescription":"ARTHROTOMY W\/BIOPSY SACROILIAC JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27052,"CodeDescription":"ARTHROTOMY W\/BIOPSY HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27052,"CodeDescription":"ARTHROTOMY W\/BIOPSY HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27052,"CodeDescription":"ARTHROTOMY W\/BIOPSY HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27052,"CodeDescription":"ARTHROTOMY W\/BIOPSY HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27052,"CodeDescription":"ARTHROTOMY W\/BIOPSY HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27054,"CodeDescription":"ARTHROTOMY W\/SYNOVECTOMY HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27057,"CodeDescription":"DCMPRN FASCIOTOMY PELVIC CMPRT DBRDMT MUSCLE UNI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27059,"CodeDescription":"RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27060,"CodeDescription":"EXCISION ISCHIAL BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27062,"CodeDescription":"EXCISION TROCHANTERIC BURSA\/CALCIFICATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27065,"CodeDescription":"EXCISION BONE CYST\/BNIGN TUMOR SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27066,"CodeDescription":"EXCISION BONE CYST\/BENIGN TUMOR DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27067,"CodeDescription":"EXC B1 CST\/B9 TUM W\/AGRFT REQ SEP INC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27070,"CodeDescription":"PARTIAL EXCISION SUPERFICIAL PELVIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27071,"CodeDescription":"PARTIAL EXCISION DEEP PELVIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27075,"CodeDescription":"RAD RESCT TUMOR WING OF ILIUM 1 PUBIC\/ISCHIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27076,"CodeDescription":"RAD RESCT TUMOR ILIUM ACETABULUM BOTH PUBIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27077,"CodeDescription":"RADICAL RESCTION TUMOR INNOMINATE BONE TOTAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27078,"CodeDescription":"RAD RESCT TUMOR ISCHIAL TUBEROSITY&GRT TRCHNTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27080,"CodeDescription":"COCCYGECTOMY PRIMARY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27086,"CodeDescription":"RMVL FOREIGN BODY PELVIS\/HIP SUBCUTANEOUS TISS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27087,"CodeDescription":"REMOVAL FOREIGN BODY PELVIS\/HIP DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27090,"CodeDescription":"REMOVAL HIP PROSTHESIS SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27091,"CodeDescription":"RMVL HIP PROSTH COMP W\/TOT HIP PROSTH MMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27093,"CodeDescription":"INJECTION HIP ARTHROGRAPHY W\/O ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27095,"CodeDescription":"INJECTION HIP ARTHROGRAPHY W\/ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27096,"CodeDescription":"INJECT SI JOINT ARTHRGRPHY&\/ANES\/STEROID W\/IMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27097,"CodeDescription":"RELEASE\/RECESSION HAMSTRING PROXIMAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27098,"CodeDescription":"TRANSFER ADDUCTOR ISCHIUM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27100,"CodeDescription":"TR XTRNL OBLQ MUSC TRCHNTR W\/FSCAL\/TDN XTN GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27105,"CodeDescription":"TR PARASPI MUSC HIP FASC\/TDN XTN GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27110,"CodeDescription":"TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27111,"CodeDescription":"TRANSFER ILIOPSOAS FEMORAL NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27120,"CodeDescription":"ACETABULOPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27122,"CodeDescription":"ACETABULOPLASTY RESECTION FEMORAL HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27125,"CodeDescription":"HEMIARTHROPLASTY HIP PARTIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27130,"CodeDescription":"ARTHRP ACETBLR\/PROX FEM PROSTC AGRFT\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27132,"CodeDescription":"CONV PREV HIP TOT HIP ARTHRP W\/WO AGRFT\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27134,"CodeDescription":"REVJ TOT HIP ARTHRP BTH W\/WO AGRFT\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27137,"CodeDescription":"REVJ TOT HIP ARTHRP ACTBLR W\/WO AGRFT\/ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27138,"CodeDescription":"REVJ TOT HIP ARTHRP FEM ONLY W\/WO ALGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27146,"CodeDescription":"OSTEOTOMY ILIAC ACETABULAR\/INNOMINATE BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27147,"CodeDescription":"OSTEOTOMY ILIAC ACETABULAR\/INNOMINATE HIP RDCTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27151,"CodeDescription":"OSTEOTOMY ILIAC ACETABULAR\/INNOMINATE FEM OSTEOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27156,"CodeDescription":"OSTEOT ILIAC ACTBLR\/INNOMINATE BONE OSTEOT RDCTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27158,"CodeDescription":"OSTEOTOMY PELVIS BILATERAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27161,"CodeDescription":"OSTEOTOMY FEMORAL NECK SEPARATE PROCEDURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27165,"CodeDescription":"OSTEOT INTERTRCHNTRIC\/SUBTRCHNTRIC W\/INT\/XTRNL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27170,"CodeDescription":"B1 GRF FEM H\/N INTERTRCHNTRIC\/SUBTRCHNTRIC AREA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27175,"CodeDescription":"TX SLP FEMORAL EPIPHYSIS TRCJ W\/O REDUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27176,"CodeDescription":"TX SLP FEM EPIPHYSIS SINGLE\/MULTIPL PINNING SITU","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27177,"CodeDescription":"OPTX SLP FEM EPIPHYSIS SINGLE\/MULT PIN\/BONE GRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27178,"CodeDescription":"OPTX SLP FEM EPIPHYSIS CLSD MANJ SINGL\/MLTPL PIN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27179,"CodeDescription":"OPTX SLP FEM EPIPHYSIS OSTPL FEM NCK HEYMAN PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27181,"CodeDescription":"OPTX SLP FEM EPIPHYSIS OSTEOT&INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27185,"CodeDescription":"EPIPHYSL ARRST EPIPHYSIOD\/STAPLING TRCHNTR FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27187,"CodeDescription":"PROPH TX N\/P\/PLTWR W\/WO MMA FEM NCK & PROX FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27197,"CodeDescription":"CLSD TX PELVIC RING FX W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27198,"CodeDescription":"CLSD TX PELVIC RING FX W\/MANIPULATION W\/ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27200,"CodeDescription":"CLOSED TREATMENT COCCYGEAL FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27202,"CodeDescription":"OPEN TREATMENT COCCYGEAL FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27215,"CodeDescription":"OPTX ILIAC TUBRST AVLS\/WING FX FIXJ IF PRFRMD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27216,"CodeDescription":"PERQ SKELETAL FIXATION PST PELVIC BONE FX&\/DIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27217,"CodeDescription":"OPTX ANT PELVIC BONE FX&\/DISLC INT FIXJ IF PFR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27218,"CodeDescription":"OPTX POST PEL BONE FX&\/DISLC INT FIXJ IF PFRMD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27220,"CodeDescription":"CLTX ACETABULUM HIP\/SOCKT FX W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27222,"CodeDescription":"CLTX ACETABULM HIP\/SOCKT FX MANJ W\/WO SKEL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27226,"CodeDescription":"OPTX PST\/ANT ACTBLR WALL FX W\/INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27227,"CodeDescription":"OPTX ACTBLR FX INVG ANT\/PST 1 COLUMN\/FX W\/INT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27228,"CodeDescription":"OPTX ACTBLR FX INVG ANT&POST 2 COLUMNS FX W\/INT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27230,"CodeDescription":"CLTX FEM FX PROX END NCK W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27232,"CodeDescription":"CLTX FEM FX PROX END NCK W\/MANJ W\/WO SKEL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27235,"CodeDescription":"PRQ SKEL FIXJ FEMORAL FX PROX END NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27236,"CodeDescription":"OPTX FEM FX PROX END NCK INT FIXJ\/PROSTC RPLCMT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27238,"CodeDescription":"CLTX INTER\/PERI\/SUBTROCHANTERIC FEM FX W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27240,"CodeDescription":"CLTX INTR\/PERI\/SBTRCHNTC FEMORAL FX W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27244,"CodeDescription":"TX INTER\/PR\/SUBTRCHNTRIC FEMORAL FX SCREW IMPLT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27245,"CodeDescription":"TX INTER\/PR\/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27246,"CodeDescription":"CLTX GREATER TROCHANTERIC FX W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27248,"CodeDescription":"OPEN TREATMENT GREATER TROCHANTERIC FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27250,"CodeDescription":"CLTX HIP DISLOCATION TRAUMATIC W\/O ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27252,"CodeDescription":"CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27253,"CodeDescription":"OPTX HIP DISLOCATION TRAUMATIC W\/O INTERNAL FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27254,"CodeDescription":"OPTX HIP DISLC TRAUMTC W\/ACTBLR WALL&FEM HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27256,"CodeDescription":"TX SPONTAN HIP DISLC ABDCT SPLNT\/TRCJ W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27257,"CodeDescription":"TX SPON HIP DISLC ABDCT SPLNT\/TRCJ W\/MANJ ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27258,"CodeDescription":"OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27259,"CodeDescription":"OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27265,"CodeDescription":"CLTX POST HIP ARTHRP DISLC W\/O ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27266,"CodeDescription":"CLTX POST HIP ARTHRP DISLC REQ ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27267,"CodeDescription":"CLOSED TX FEMORAL FRACTURE PROX HEAD W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27268,"CodeDescription":"CLOSED TX FEMORAL FRACTURE PROX HEAD W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27269,"CodeDescription":"OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27275,"CodeDescription":"MANIPULATION HIP JOINT GENERAL ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27279,"CodeDescription":"ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27280,"CodeDescription":"ARTHRODESIS SI JT OPN W\/OBTAINING B1 GRF INSTRMJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27282,"CodeDescription":"ARTHRODESIS SYMPHYSIS PUBIS W\/OBTAINING GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27284,"CodeDescription":"ARTHRODESIS HIP JOINT W\/OBTAINING GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27286,"CodeDescription":"ARTHRD HIP JT W\/OBTG GRF W\/SUBTRCHNTRIC OSTEOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27290,"CodeDescription":"INTERPELVIABDOMINAL AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27295,"CodeDescription":"DISARTICULATION HIP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27299,"CodeDescription":"UNLISTED PROCEDURE PELVIS\/HIP JOINT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27301,"CodeDescription":"I&D DEEP ABSC BURSA\/HEMATOMA THIGH\/KNEE REGION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27303,"CodeDescription":"INC DEEP W\/OPNG BONE CORTEX FEMUR\/KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27305,"CodeDescription":"FASCIOTOMY ILIOTIBIAL OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27306,"CodeDescription":"TENOTOMY PRQ ADDUCTOR\/HAMSTRING 1 TENDON SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27307,"CodeDescription":"TENOTOMY PRQ ADDUCTOR\/HAMSTRING MULTIPLE TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27310,"CodeDescription":"ARTHRT KNE W\/EXPL DRG\/RMVL FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27323,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27323,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27323,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27323,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27323,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27324,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27324,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27324,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27324,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27324,"CodeDescription":"BIOPSY SOFT TISSUE THIGH\/KNEE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27325,"CodeDescription":"NEURECTOMY HAMSTRING MUSCLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27326,"CodeDescription":"NEURECTOMY POPLITEAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27327,"CodeDescription":"EXCISION TUMOR SOFT TISSUE THIGH\/KNEE SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27328,"CodeDescription":"EXC TUMOR SOFT TISSUE THIGH\/KNEE SUBFASC  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27329,"CodeDescription":"RAD RESECT TUMOR SOFT TISSUE THIGH\/KNEE  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27330,"CodeDescription":"ARTHROTOMY KNEE W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27330,"CodeDescription":"ARTHROTOMY KNEE W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27330,"CodeDescription":"ARTHROTOMY KNEE W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27330,"CodeDescription":"ARTHROTOMY KNEE W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27330,"CodeDescription":"ARTHROTOMY KNEE W\/SYNOVIAL BIOPSY ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27331,"CodeDescription":"ARTHRT KNE W\/JT EXPL BX\/RMVL LOOSE\/FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27332,"CodeDescription":"ARTHRT W\/EXC SEMILUNAR CRTLG KNEE MEDIAL\/LAT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27333,"CodeDescription":"ARTHRT W\/EXC SEMILUNAR CRTLG KNEE MEDIAL&LAT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27334,"CodeDescription":"ARTHROTOMY W\/SYNOVECTOMY KNEE ANTERIOR\/POSTERIOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27335,"CodeDescription":"ARTHRT W\/SYNVCT KNE ANT&POST W\/POP AREA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27337,"CodeDescription":"EXCISON TUMOR SOFT TISSUE THIGH\/KNEE SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27339,"CodeDescription":"EXC TUMOR SOFT TISSUE THIGH\/KNEE SUBFASC 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27340,"CodeDescription":"EXCISION PREPATELLAR BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27345,"CodeDescription":"EXCISION SYNOVIAL CYST POPLITEAL SPACE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27347,"CodeDescription":"EXCISION LESION MENISCUS\/CAPSULE KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27350,"CodeDescription":"PATELLECTOMY\/HEMIPATELLECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27355,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27356,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR FEMUR W\/ALLOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27357,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR FEMUR W\/AUTOGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27358,"CodeDescription":"EXCISION\/CURETTAGE CYST\/TUMOR FEMUR INT FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27360,"CodeDescription":"PRTL EXC BONE FEMUR PROX TIBIA&\/FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27364,"CodeDescription":"RAD RESECTION TUMOR SOFT TIS THIGH\/KNEE 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27365,"CodeDescription":"RADICAL RESECTION TUMOR FEMOR OR KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27369,"CodeDescription":"NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT\/MRI KNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27369,"CodeDescription":"NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT\/MRI KNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27369,"CodeDescription":"NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT\/MRI KNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27369,"CodeDescription":"NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT\/MRI KNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27369,"CodeDescription":"NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT\/MRI KNE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27372,"CodeDescription":"REMOVAL FOREIGN BODY DEEP THIGH\/KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27380,"CodeDescription":"SUTURE INFRAPATELLAR TENDON PRIMARY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27381,"CodeDescription":"SUTR INFRAPATELLAR TDN 2 RCNSTJ W\/FSCAL\/TDN GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27385,"CodeDescription":"SUTURE QUADRICEPS\/HAMSTRING RUPTURE PRIMARY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27386,"CodeDescription":"SUTR QUADRICEPS\/HAMSTRING MUSC RPT RCNSTJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27390,"CodeDescription":"TENOTOMY OPEN HAMSTRING KNEE HIP SINGLE TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27391,"CodeDescription":"TENOTOMY OPN HAMSTRING KNEE HIP MULTIPLE 1 LEG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27392,"CodeDescription":"TENOTOMY OPEN HAMSTRING KNEE HIP MULTIPLE BI","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27393,"CodeDescription":"LENGTHENING HAMSTRING TENDON SINGLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27394,"CodeDescription":"LENGTHENING HAMSTRING TENDON MULTIPLE 1 LEG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27395,"CodeDescription":"LENGTHENING HAMSTRING TENDON MULTIPLE BILATERAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27400,"CodeDescription":"TRANSFER TENDON\/MUSCLE HAMSTRINGS FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27403,"CodeDescription":"ARTHROTOMY W\/MENISCUS REPAIR KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27405,"CodeDescription":"RPR PRIMARY TORN LIGM&\/CAPSULE KNEE COLLATERAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27407,"CodeDescription":"REPAIR PRIMARY TORN LIGM&\/CAPSULE KNEE CRUCIAT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27409,"CodeDescription":"RPR 1 TORN LIGM&\/CAPSL KNE COLTRL&CRUCIATE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27412,"CodeDescription":"AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27415,"CodeDescription":"OSTEOCHONDRAL ALLOGRAFT KNEE OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27416,"CodeDescription":"OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27418,"CodeDescription":"ANTERIOR TIBIAL TUBERCLEPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27420,"CodeDescription":"RCNSTJ DISLOCATING PATELLA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27422,"CodeDescription":"RCNSTJ DISLC PATELLA W\/XTNSR RELIGNMT&\/MUSC RL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27424,"CodeDescription":"RCNSTJ DISLC PATELLA W\/PATELLECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27425,"CodeDescription":"LATERAL RETINACULAR RELEASE OPEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27427,"CodeDescription":"LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27428,"CodeDescription":"LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27429,"CodeDescription":"LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27430,"CodeDescription":"QUADRICEPSPLASTY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27435,"CodeDescription":"CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27437,"CodeDescription":"ARTHROPLASTY PATELLA W\/O PROSTHESIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27438,"CodeDescription":"ARTHROPLASTY PATELLA W\/PROSTHESIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27440,"CodeDescription":"ARTHROPLASTY KNEE TIBIAL PLATEAU","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27441,"CodeDescription":"ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27442,"CodeDescription":"ARTHROPLASTY FEM CONDYLES\/TIBIAL PLATEAU KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27443,"CodeDescription":"ARTHRP FEM CONDYLES\/TIBL PLATU KNE DBRDMT&PRTL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27445,"CodeDescription":"ARTHROPLASTY KNEE HINGE PROSTHESIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27446,"CodeDescription":"ARTHRP KNEE CONDYLE&PLATEAU MEDIAL\/LAT CMPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27447,"CodeDescription":"ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT COMPARTMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27448,"CodeDescription":"OSTEOTOMY FEMUR SHAFT\/SUPRACONDYLAR W\/O FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27450,"CodeDescription":"OSTEOTOMY FEMUR SHAFT\/SUPRACONDYLAR W\/FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27454,"CodeDescription":"OSTEOT MLT W\/RELIGNMT IMED ROD FEM SHFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27455,"CodeDescription":"OSTEOT PROX TIBIA FIB EXC\/OSTEOT BEFORE EPIPHYSL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27457,"CodeDescription":"OSTEOT PROX TIBIA FIB EXC\/OSTEOT AFTER EPIPHYSL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27465,"CodeDescription":"OSTEOPLASTY FEMUR SHORTENING EXCLUDING 64876","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27466,"CodeDescription":"OSTEOPLASTY FEMUR LENGTHENING","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27468,"CodeDescription":"OSTPL FEMUR CMBN LNGTH&SHRT W\/FEMORAL SGM TRNSFR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27470,"CodeDescription":"RPR NON\/MAL FEMUR DSTL H\/N W\/O GRF","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27472,"CodeDescription":"RPR NON\/MAL FEMUR DSTL H\/N W\/ILIAC\/AUTOG BONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27475,"CodeDescription":"ARREST EPIPHYSEAL DISTAL FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27477,"CodeDescription":"ARREST EPIPHYSEAL TIBIA & FIBULA PROXIMAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27479,"CodeDescription":"ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27485,"CodeDescription":"ARRST HEMIEPIPHYSL DSTL FEMUR\/PROX TIBIA\/FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27486,"CodeDescription":"REVJ TOTAL KNEE ARTHRP W\/WO ALGRFT 1 COMPONENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27487,"CodeDescription":"REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27488,"CodeDescription":"RMVL PROSTH TOT KNEE PROSTH MMA W\/WO INSJ SPACER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27495,"CodeDescription":"PROPH TX N\/P\/PLTWR W\/WO METHYLMETHACRYLATE FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27496,"CodeDescription":"DECOMPRESSION FASCIOTOMY THIGH&\/KNEE 1 COMPONENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27497,"CodeDescription":"DCMPRN FASCT THIGH&\/KNEE DBRDMT MUSCLE&\/NERVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27498,"CodeDescription":"DCMPRN FASCIOTOMY THIGH&\/KNEE MLT COMPARTMENTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27499,"CodeDescription":"DCMPRN FASCT THIGH&\/KNEE MLT DBRDMT NV MUSC&NRVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27500,"CodeDescription":"CLOSED TX FEMORAL SHAFT FX W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27501,"CodeDescription":"CLTX SPRCNDYLR\/TRNSCNDYLR FEM FX W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27502,"CodeDescription":"CLTX FEM SHFT FX W\/MANJ W\/WO SKIN\/SKELETAL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27503,"CodeDescription":"CLTX SPRCNDYLR\/TRNSCNDYLR FEM FX W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27506,"CodeDescription":"OPTX FEM SHFT FX W\/INSJ IMED IMPLT W\/WO SCREW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27507,"CodeDescription":"OPTX FEM SHFT FX W\/PLATE\/SCREWS W\/WO CERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27508,"CodeDescription":"CLTX FEM FX DSTL END MEDIAL\/LAT CONDYLE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27509,"CodeDescription":"PRQ SKELETAL FIXJ FEMORAL FX DISTAL END","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27510,"CodeDescription":"CLTX FEM FX DSTL END MEDIAL\/LAT CONDYLE W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27511,"CodeDescription":"OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W\/O XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27513,"CodeDescription":"OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W\/XTN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27514,"CodeDescription":"OPEN TX FEMORAL FRACTURE DISTAL MED\/LAT CONDYLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27516,"CodeDescription":"CLTX DISTAL FEMORAL EPIPHYSL SEPARATION W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27517,"CodeDescription":"CLTX DSTL FEM EPIPHYSL SEP W\/MANJ W\/WO SKIN\/SKEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27519,"CodeDescription":"OPEN TX DISTAL FEMORAL EPIPHYSEAL SEPARATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27520,"CodeDescription":"CLOSED TX PATELLAR FRACTURE W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27524,"CodeDescription":"OPTX PATLLR FX W\/INT FIXJ\/PATLLC&SOFT TISS RPR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27530,"CodeDescription":"CLTX TIBIAL FX PROXIMAL W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27532,"CodeDescription":"CLTX TIBIAL FX PROXIMAL W\/WO MANJ W\/SKEL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27535,"CodeDescription":"OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27536,"CodeDescription":"OPTX TIBIAL FX PROX BICONDYLAR W\/WO INT FIXJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27538,"CodeDescription":"CLTX INTERCONDYLAR SPI&\/TUBRST FX KNE W\/WO MAN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27540,"CodeDescription":"OPEN TX INTERCONDYLAR SPINE\/TUBRST FRACTURE KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27550,"CodeDescription":"CLOSED TX KNEE DISLOCATION W\/O ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27552,"CodeDescription":"CLOSED TX KNEE DISLOCATION W\/ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27556,"CodeDescription":"OPEN TX KNEE DISLOCATION W\/O LIGAMENTOUS REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27557,"CodeDescription":"OPEN TX KNEE DISLOCATION W\/LIGAMENTOUS REPAIR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27558,"CodeDescription":"OPEN TX KNEE DISLOCATION W\/REPAIR\/RECONSTRUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27560,"CodeDescription":"CLOSED TX PATELLAR DISLOCATION W\/O ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27562,"CodeDescription":"CLOSED TX PATELLAR DISLOCATION W\/ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27566,"CodeDescription":"OPTX PATELLAR DISLC W\/WO PRTL\/TOT PATELLECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27570,"CodeDescription":"MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27580,"CodeDescription":"ARTHRODESIS KNEE ANY TECHNIQUE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27590,"CodeDescription":"AMPUTATION THIGH THROUGH FEMUR ANY LEVEL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27591,"CodeDescription":"AMP THI THRU FEMUR LVL IMMT FITG TQ W\/1ST CST","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27592,"CodeDescription":"AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27594,"CodeDescription":"AMP THIGH THRU FEMUR SEC CLOSURE\/SCAR REVISION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27596,"CodeDescription":"AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27598,"CodeDescription":"DISARTICULATION KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27599,"CodeDescription":"UNLISTED PROCEDURE FEMUR\/KNEE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27600,"CodeDescription":"DCMPRN FASCT LEG ANT&\/LAT COMPARTMENTS ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27601,"CodeDescription":"DCMPRN FASCT LEG POST COMPARTMENT ONLY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27602,"CodeDescription":"DCMPRN FASCT LEG ANT&\/LAT&PST CMPRT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27603,"CodeDescription":"INCISION & DRAINAGE LEG\/ANKLE ABSCESS\/HEMATOMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27604,"CodeDescription":"INCISION & DRAINAGE LEG\/ANKLE INFECTED BURSA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27605,"CodeDescription":"TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27606,"CodeDescription":"TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27607,"CodeDescription":"INCISION LEG\/ANKLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27610,"CodeDescription":"ARTHROTOMY ANKLE W\/EXPL DRAINAGE\/REMOVAL FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27612,"CodeDescription":"ARTHRT PST CAPSUL RLS ANKLE W\/WO ACHLL TDN LNGTH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27613,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27613,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27613,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27613,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27613,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA SUPERFICIAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27614,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27614,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27614,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27614,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27614,"CodeDescription":"BIOPSY SOFT TISSUE LEG\/ANKLE AREA DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27615,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE LEG\/ANKLE  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27616,"CodeDescription":"RAD RESECTION TUMOR SOFT TISSUE LEG\/ANKLE 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27618,"CodeDescription":"EXC TUMOR SOFT TISSUE LEG\/ANKLE SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27619,"CodeDescription":"EXC TUMOR SOFT TISSUE LEG\/ANKLE SUBFASCIAL  LT 5CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27620,"CodeDescription":"ARTHRT ANKLE W\/EXPL W\/WO BX W\/WO RMVL LOOSE\/FB","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27625,"CodeDescription":"ARTHROTOMY W\/SYNOVECTOMY ANKLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27626,"CodeDescription":"ARTHROTOMY W\/SYNOVECTOMY ANKLE TENOSYNOVECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27630,"CodeDescription":"EXCISION LESION TENDON SHEATH\/CAPSULE LEG&\/ANK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27632,"CodeDescription":"EXCISION TUMOR SOFT TISSUE LEG\/ANKLE SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27634,"CodeDescription":"EXC TUMOR SOFT TISSUE LEG\/ANKLE SUBFASC 5 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27635,"CodeDescription":"EXCISION\/CURETTAGE BONE CYST\/TUMOR TIBIA\/FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27637,"CodeDescription":"EXC\/CURETTAGE CYST\/TUMOR TIBIA\/FIBULA W\/AGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27638,"CodeDescription":"EXC\/CURETTAGE CYST\/TUMOR TIBIA\/FIBULA W\/ALGRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27640,"CodeDescription":"PARTIAL EXCISION BONE TIBIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27641,"CodeDescription":"PARTIAL EXCISION BONE FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27645,"CodeDescription":"RADICAL RESECTION OF TUMOR TIBIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27646,"CodeDescription":"RADICAL RESECTION TUMOR BONE FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27647,"CodeDescription":"RADICAL RESECTION OF TUMOR TALUS OR CALCANEUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27648,"CodeDescription":"INJECTION ANKLE ARTHROGRAPHY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27650,"CodeDescription":"REPAIR PRIMARY OPEN\/PRQ RUPTURED ACHILLES TENDON","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27652,"CodeDescription":"RPR PRIMARY OPEN\/PRQ RUPTURED ACHILLES W\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27654,"CodeDescription":"REPAIR SECONDARY ACHILLES TENDON W\/WO GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27656,"CodeDescription":"REPAIR FASCIAL DEFECT LEG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27658,"CodeDescription":"REPAIR FLEXOR TENDON LEG PRIMARY W\/O GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27659,"CodeDescription":"RPR FLEXOR TENDON LEG SECONDARY W\/O GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27664,"CodeDescription":"RPR EXTENSOR TENDON LEG PRIMARY W\/O GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27665,"CodeDescription":"RPR EXTENSOR TENDON LEG SECONDRY W\/WO GRAFT EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27675,"CodeDescription":"RPR DISLOC PERONEAL TENDON W\/O FIBULAR OSTEOTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27676,"CodeDescription":"REPAIR DISLOCATING PERONEAL TENDON W\/FIB OSTEOT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27680,"CodeDescription":"TENOLYSIS FLXR\/XTNSR TENDON LEG&\/ANKLE 1 EACH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27681,"CodeDescription":"TNOLS FLXR\/XTNSR TDN LEG&\/ANKLE MLT TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27685,"CodeDescription":"LNGTH\/SHRT TENDON LEG\/ANKLE 1 TENDON SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27686,"CodeDescription":"LNGTH\/SHRT TDN LEG\/ANKLE MLT TDN SAME INC EA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27687,"CodeDescription":"GASTROCNEMIUS RECESSION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27690,"CodeDescription":"TR\/TRNSPL 1 TDN W\/MUSC REDIRION\/REROUTING SUPFC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27691,"CodeDescription":"TR\/TRNSPL 1 TDN W\/MUSC REDIRION\/REROUTING DP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27692,"CodeDescription":"TR\/TRNSPL 1 TDN W\/MUSC REDIRION\/REROUTING EA TDN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27695,"CodeDescription":"RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27696,"CodeDescription":"RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27698,"CodeDescription":"REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27700,"CodeDescription":"ARTHROPLASTY ANKLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27702,"CodeDescription":"ARTHROPLASTY ANKLE W\/IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27703,"CodeDescription":"ARTHROPLASTY ANKLE REVISION TOTAL ANKLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27704,"CodeDescription":"REMOVAL ANKLE IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27705,"CodeDescription":"OSTEOTOMY TIBIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27707,"CodeDescription":"OSTEOTOMY FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27709,"CodeDescription":"OSTEOTOMY TIBIA & FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27712,"CodeDescription":"OSTEOT MLT W\/RELIGNMT IMED ROD","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27715,"CodeDescription":"OSTEOPLASTY TIBIA & FIBULA LENGTHENING\/SHORTENIN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27720,"CodeDescription":"REPAIR NONUNION\/MALUNION TIBIA W\/O GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27722,"CodeDescription":"REPAIR NONUNION\/MALUNION TIBIA W\/SLIDING GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27724,"CodeDescription":"RPR NON\/MAL TIBIA W\/ILIAC\/OTH AGRFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27725,"CodeDescription":"RPR NON\/MAL TIBIA SYNOSTOSIS W\/FIBULA ANY METH","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27726,"CodeDescription":"REPAIR FIBULA NONUNION\/MALUNION W\/INT FIXATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27727,"CodeDescription":"REPAIR CONGENITAL PSEUDARTHROSIS TIBIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27730,"CodeDescription":"ARREST EPIPHYSEAL OPEN DISTAL TIBIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27732,"CodeDescription":"ARREST EPIPHYSEAL OPEN DISTAL FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27734,"CodeDescription":"ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27740,"CodeDescription":"ARREST EPIPHYSEAL ANY METHOD TIBIA & FIBULA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27742,"CodeDescription":"ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27745,"CodeDescription":"PROPH TX N\/P\/PLTWR W\/WO METHYLMETHACRYLATE TIBIA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27750,"CodeDescription":"CLTX TIBIAL SHAFT FX W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27752,"CodeDescription":"CLTX TIBIAL SHAFT FX W\/MANJ W\/WO SKEL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27756,"CodeDescription":"PRQ SKELETAL FIXATION TIBIAL SHAFT FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27758,"CodeDescription":"OPTX TIBIAL SHFT FX W\/PLATE\/SCREWS W\/WO CERCLAGE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27759,"CodeDescription":"TX TIBL SHFT FX IMED IMPLT W\/WO SCREWS&\/CERCLA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27760,"CodeDescription":"CLTX MEDIAL MALLEOLUS FX W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27762,"CodeDescription":"CLTX MEDIAL MALLS FX W\/MANJ W\/WO SKN\/SKEL TRACJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27766,"CodeDescription":"OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27767,"CodeDescription":"CLOSED TREATMENT PST MALLEOLUS FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27768,"CodeDescription":"CLOSED TREATMENT PST MALLEOLUS FRACTURE W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27769,"CodeDescription":"OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27780,"CodeDescription":"CLTX PROX FIBULA\/SHFT FX W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27781,"CodeDescription":"CLTX PROX FIBULA\/SHFT FX W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27784,"CodeDescription":"OPEN TREATMENT PROXIMAL FIBULA\/SHAFT FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27786,"CodeDescription":"CLTX DSTL FIBULAR FX LAT MALLS W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27788,"CodeDescription":"CLTX DSTL FIBULAR FX LAT MALLS W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27792,"CodeDescription":"OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27802,"CodeDescription":"TREAT LOWER LEG FRACTURES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27808,"CodeDescription":"CLOSED TX BIMALLEOLAR ANKLE FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27808,"CodeDescription":"CLOSED TX BIMALLEOLAR ANKLE FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27808,"CodeDescription":"CLOSED TX BIMALLEOLAR ANKLE FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27808,"CodeDescription":"CLOSED TX BIMALLEOLAR ANKLE FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27808,"CodeDescription":"CLOSED TX BIMALLEOLAR ANKLE FRACTURE W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":27810,"CodeDescription":"CLOSED TX BIMALLEOLAR ANKLE FRACTURE W\/MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27814,"CodeDescription":"OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27816,"CodeDescription":"CLTX TRIMALLEOLAR ANKLE FX W\/O MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27818,"CodeDescription":"CLTX TRIMALLEOLAR ANKLE FX W\/MANIPULATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27822,"CodeDescription":"OPEN TX TRIMALLEOLAR ANKLE FX W\/O FIXJ PST LIP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27823,"CodeDescription":"OPEN TX TRIMALLEOLAR ANKLE FX W\/FIXJ PST LIP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":27824,"CodeDescription":"CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W\/O MANJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN mem