[{"Code":"0001A","CodeDescription":"IMM ADMN SARSCOV2 30MCG\/0.3ML DIL RECON 1ST DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0001F","CodeDescription":"HRT FAILURE ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0002A","CodeDescription":"IMM ADMN SARSCOV2 30MCG\/0.3ML DIL RECON 2ND DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0002M","CodeDescription":"LIVER DIS 10 ASSAYS SERUM ALGORITHM W\/ASH","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0002U","CodeDescription":"ONC CLRCT QUAN 3 UR METABOLITES ALG ADNMTS PLP","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0003A","CodeDescription":"IMM ADMN SARSCOV2 30MCG\/0.3ML DIL RECON 3RD DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0003M","CodeDescription":"LIVER DIS 10 ASSAYS SERUM ALGORITHM W\/NASH","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0003U","CodeDescription":"ONC OVARIAN ASSAY 5 PROTEINS SERUM ALG SCOR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"0004A","CodeDescription":"IMM ADMN SARSCOV2 30MCG\/0.3ML DIL RECON BST DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0004M","CodeDescription":"SCOLIOSIS 53 SNPS SALIVA PROGNOSTIC RISK SCORE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0005F","CodeDescription":"OSTEOARTHRITIS COMPOSITE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0005U","CodeDescription":"ONCO PRST8 GENE XPRS PRFL 3 GENE UR ALG RSK SCOR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0006M","CodeDescription":"ONCOLOGY HEP MRNA 161 GENES RISK CLASSIFIER","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0007M","CodeDescription":"ONCOLOGY GASTRO 51 GENES NOMOGRAM DISEASE INDEX","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"0008U","CodeDescription":"HPYLORI DETECTION & ANTIBIOTIC RESISTANCE DNA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0009U","CodeDescription":"ONC BRST CA ERBB2 COPY NUMBER FISH AMP\/NONAMP","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0010U","CodeDescription":"NFCT DS STRN TYP WHL GENOME SEQUENCING PR ISOL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0011A","CodeDescription":"IMM ADMN SARSCOV2 100 MCG\/0.5 ML 1ST DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0011M","CodeDescription":"ONC PRST8 CA MRNA 12 GENES BLD PLSM &\/UR ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0011U","CodeDescription":"RX MNTR DRUGS PRESENT LC-MS\/MS ORAL FLUID PR DOS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0012A","CodeDescription":"IMM ADMN SARSCOV2 100 MCG\/0.5 ML 2ND DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0012F","CodeDescription":"COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA ASSMT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0012M","CodeDescription":"ONC MRNA 5 GENES UR ALG RISK UROTHELIAL CANCER","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0013A","CodeDescription":"IMM ADMN SARSCOV2 100 MCG\/0.5 ML 3RD DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0013M","CodeDescription":"ONC MRNA 5 GENES UR ALG RISK RECR UROTHELIAL CA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0014A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0014F","CodeDescription":"COMP PREOP ASSESS CATARACT SURG W\/IOL PLACEMNT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"0015F","CodeDescription":"MELANOMA FOLLOW UP COMPLETED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0015M","CodeDescription":"ADRENAL CORTICAL TUM BIOCHEM ASSAY 25 STRD MRK","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0016M","CodeDescription":"ONC BLADDER MRNA MICRORA GEN XPRSN PRFLG 219 ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0016U","CodeDescription":"ONC HMTLMF NEO RNA BCR\/ABL1 BLD\/BNE MARROW","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0018M","CodeDescription":"TRNSPLJ RNL RJCTN MEAS CD154+T CLL WHL PRPH BLD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0018U","CodeDescription":"ONC THYR 10 MICRORNA SEQ +\/- RSLT MOD HI RSK MAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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":"0019M","CodeDescription":"CV DS PLSM ALYS PRTN BMRK APTAMR-BSD MICRORA&ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0019U","CodeDescription":"ONC RNA WHL TRANSCIPTOME SEQ TISS PREDCT ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0021U","CodeDescription":"ONC PRST8 DETCJ 8 AUTOANTIBODIES ALG RSK SCOR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"TGSAP NONSMALL CELL LUNG NEO DNA&RNA 23 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":"0023A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0023U","CodeDescription":"ONC AML DNA GNTYP INT TANDEM DUP DETCJ\/NONDETCJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0024A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0024U","CodeDescription":"GLYCA NUC MR SPECTROSCOPY QUANTITATIVE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0025U","CodeDescription":"TENOFOVIR LIQ CHROM TANDEM MASS SPECT UR 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\/ 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":"0032A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0032U","CodeDescription":"COMT GENE ANALYSIS C.472G GT A VARIANT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0033A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always 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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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0036U","CodeDescription":"EXOME TUMOR TISSUE & NORMAL SPECIMEN SEQ ALYS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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 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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":"0039U","CodeDescription":"DNA ANTIBODY DOUBLE STRANDED HIGH AVIDITY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Required 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PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"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)","BenefitDetail":"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":"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":"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":"0042T","CodeDescription":"CEREBRAL PERFUSION ANALYS CT W\/BLOOD FLOW&VOLUME","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0043A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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 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that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0045U","CodeDescription":"ONC BRST DUX CARC IS MRNA 12 GENES ALG RSK SCOR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0046U","CodeDescription":"FLT3 GENE INT TANDEM DUPL VARIANTS QUANTITATIVE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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 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Facility","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":"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":"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 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Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","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":"SFN or CLN member at ZSFGH","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 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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":"0054A","CodeDescription":"IMM ADMN SARSCOV2 30MCG\/0.3ML TRIS-SUCROSE BST","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0054T","CodeDescription":"CPTR-ASST MUSCSKEL NAVIGJ ORTHO FLUOR IMAGES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"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":"0055T","CodeDescription":"CPTR-ASST MUSCSKEL NAVIGJ ORTHO CT\/MRI","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0055U","CodeDescription":"CARD HRT TRNSPL 96 TARGET DNA SEQUENCES PLASMA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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 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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":"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":"0060U","CodeDescription":"TWN ZYG GEN TRGT SEQ ALYS CHRMS2 FTL DNA MAT BLD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0061A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0061U","CodeDescription":"TC MEAS 5 BIOMARKERS W\/SFDI MULTI-SPECTRAL ALYS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"00622","CodeDescription":"ANESTH REMOVAL OF NERVES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0062A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0062U","CodeDescription":"AI SLE IGG & IGM ALYS 80 BMRK SRM ALG RSK SCORE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"00634","CodeDescription":"ANESTH FOR CHEMONUCLEOLYSIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0063A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0063U","CodeDescription":"NEURO AUTISM 32 AMINES PLSM ALG METAB SIGNATURE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0064A","CodeDescription":"IMM ADMN SARSCOV2 50 MCG\/0.25 ML BOOSTER DOSE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0067U","CodeDescription":"ONC BRST IMHCHEM PRTN XPRS PRFL 4 BMRK CA PRTN","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0069U","CodeDescription":"ONC CLRCT MICRORNA XPRS PRFL MIR-31-3P ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0070U","CodeDescription":"CYP2D6 GENE ANALYSIS COMMON & SELECT RARE VRNTS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0071A","CodeDescription":"IMM ADMN SARSCOV2 10MCG\/0.2ML TRIS-SUCROSE 1ST","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0071T","CodeDescription":"US ABLATJ UTERINE LEIOMYOMATA LT 200 CC TISSUE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0071U","CodeDescription":"CYP2D6 GENE ANALYSIS FULL GENE SEQUENCE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0072A","CodeDescription":"IMM ADMN SARSCOV2 10MCG\/0.2ML TRIS-SUCROSE 2ND","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0072T","CodeDescription":"US ABLATJ UTERINE LEIOMYOMAT GE EQUAL 200 CC TISS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0072U","CodeDescription":"CYP2D6 GENE TRGT SEQ ALYS CYP2D6-2D7 HYBRID GENE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0073A","CodeDescription":"IMM ADMN SARSCOV2 10MCG\/0.2ML TRIS-SUCROSE 3RD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0073U","CodeDescription":"CYP2D6 GENE TRGT SEQ ALYS CYP2D7-2D6 HYBRID GENE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0074A","CodeDescription":"IMM ADMN SARSCOV2 10MCG\/0.2ML TRIS-SUCROSE BST","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0074U","CodeDescription":"CYP2D6 TRGT SEQ ALYS NONDUP GENE DUPL\/MLT TRANS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0075T","CodeDescription":"TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0075U","CodeDescription":"CYP2D6 GENE TRGT SEQ ALYS 5' GENE DUPL\/MLT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0076T","CodeDescription":"TCAT PLMT XTRC VRT CRTD STENT RS&IPRQ EA VSL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0076U","CodeDescription":"CYP2D6 GENE TRGT SEQ ALYS 3' GENE DUPL\/MLT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"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":"0078U","CodeDescription":"PAIN MGT OPIOID USE DO GNOTYP PNL 16 CMN VRNTS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0079U","CodeDescription":"CMPRTV DNA ALYS MLT SNPS UR&BUCCAL SPEC ID VERIF","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0080U","CodeDescription":"ONC LUNG 5 CLINICAL RISK FACTORS ALG PRBLTY MAL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0081A","CodeDescription":"IMM ADMN SARSCOV2 3MCG\/0.2ML TRIS-SUCROSE 1ST","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0082A","CodeDescription":"IMM ADMN SARSCOV2 3MCG\/0.2ML TRIS-SUCROSE 2ND","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"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":"0083A","CodeDescription":"IMM ADMN SARSCOV2 3MCG\/0.2ML TRIS-SUCROSE 3RD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0083U","CodeDescription":"ONC RSPSE CHEMOTX RX MOTILITY CNTRST TOMOGRAPHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0084A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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":"0086U","CodeDescription":"NFCT DS BACT&FNG ORG ID BLD CUL RRNA FISH 6+TRGT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0089U","CodeDescription":"ONC MLNMA GEN XPRS PRFL RTQPCR PRAME & LINC00518","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0090U","CodeDescription":"ONC CUTAN MLNMA MRNA GEN XPRS PRFL 23 GENES ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0091A","CodeDescription":"IMM ADMN SARSCOV2 50 MCG\/0.5 ML 1ST DOSE 6-11","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0091U","CodeDescription":"ONC CLRCT SCR CLL ENUM CRCG TUM CLL WHL BLD ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"00921","CodeDescription":"ANES VASECTOMY UNI\/BI INCL OPEN URETHRAL PX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"Service related to family planning or related to testing for sexually transmitted infections","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":"0092A","CodeDescription":"IMM ADMN SARSCOV2 50 MCG\/0.5 ML 2ND DOSE 6-11","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0092U","CodeDescription":"ONC LUNG 3 PRTN BMRK IA PLSM ALG RSK SCOR MALIG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0093A","CodeDescription":"IMM ADMN SARSCOV2 50 MCG\/0.5 ML 3RD DOSE 6-11","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0093U","CodeDescription":"RX MNTR 65 COM DRUGS LC-MS\/MS UR DETC\/NOT DETC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0094A","CodeDescription":"IMM ADMN SARSCOV2 50 MCG\/0.5 ML BOOSTER DOSE 18+","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0094U","CodeDescription":"GENOME RAPID SEQUENCE ANALYSIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0095T","CodeDescription":"RMVL TOT DISC ARTHRP ANT APPR CRV EA NTRSPC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0095U","CodeDescription":"EE&MAJ BASIC PRTN ELISA ESOPHGL STRING TST DEV","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0096U","CodeDescription":"HPV HIGH RISK TYPES MALE URINE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0098T","CodeDescription":"REVJ TOT DISC ARTHRP ANT APPR CRV EA NTRSPC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"00999","CodeDescription":"SALES TAX","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0100T","CodeDescription":"PLMT SCJNCL RTA PROSTH&PLS&IMPLTJ INTRA-OC RTA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0101A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0101T","CodeDescription":"EXTRACORPOREAL SHOCK WAVE MUSCSKEL SYS NOS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0101U","CodeDescription":"HERED COLON CA DO GEN SEQ ALYS PANEL 15 GENES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0102A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0102T","CodeDescription":"ESW BY PHYS W\/ANES INVG LAT HUMERL EPICONDYLE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0102U","CodeDescription":"HERED BRST CA RLTD DO GEN SEQ ALYS PNL 17 GENES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0103A","CodeDescription":"PLACEHOLDER ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0103U","CodeDescription":"HERED OVARIAN CANCER GEN SEQ ALYS PANEL 24 GENES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0105U","CodeDescription":"NEPHROLOGY CKD ECLIA TUMOR NECROSIS ALG RKFD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0106T","CodeDescription":"QUANT SENSORY TEST&INTERPJ\/XTR W\/TOUCH STIMULI","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0106U","CodeDescription":"GASTRIC EMPTYING SERIAL COLLJ 7 TIMED BRTH SPEC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0107T","CodeDescription":"QUANT SENSORY TEST&INTERPJ\/XTR W\/VIBRJ STIMULI","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"0108T","CodeDescription":"QUANT SENSORY TEST&INTERPJ\/XTR W\/COOL STIMULI","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0108U","CodeDescription":"GI BARRETTS ESOPH QUAN IMMUNOLABEL 9 PRTN BMRK","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0109T","CodeDescription":"QUANT SENAORY TEST&INTERPJ\/XTR W\/HT-PN STIMULI","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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 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schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0115U","CodeDescription":"RESPIR IADNA 18 VIRAL TYPE&SUBTYPE & 2 BACT TRGT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0116U","CodeDescription":"RX MNTR NZM IA 35+DRUGS LC-MS\/MS ORAL FLUID ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0117U","CodeDescription":"PAIN MGMT ALYS 11 ENDOGENOUS ANALYTES URINE ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0118U","CodeDescription":"TRANSPLANTATION MED QUAN DON-DRV CLL-FR DNA PLSM","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0119U","CodeDescription":"CARDIOLOGY CERAMIDES LIQ CHROM TANDEM MS PLASMA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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":"0121U","CodeDescription":"SICKLE CELL DISEASE VCAM-1 WHOLE BLOOD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0122U","CodeDescription":"SICKLE CELL DISEASE P-SELECTIN WHOLE BLOOD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0123U","CodeDescription":"MCHNL FRGLTY RBC SHEAR STRS&SPECTRAL ALYS PRFLG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0129U","CodeDescription":"HEREDITARY BRST CA RLTD DO GEN SEQ&DEL\/DUP PNL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0130U","CodeDescription":"HEREDITARY COLON CA DO TRGT MRNA SEQ ALYS PANEL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0131U","CodeDescription":"HERED BRST CA RLTD DO TRGT MRNA SEQ ALYS 13 GENE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0132U","CodeDescription":"HERED OVA CA RLTD DO TRGT MRNA SEQ ALYS 17 GENE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0133U","CodeDescription":"HERED PRST8 CA RLTD DO TRGT MRNA SEQ ALYS 11 GEN","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0134U","CodeDescription":"HEREDITARY PAN CA TRGT MRNA SEQ ALYS 18 GENE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0135U","CodeDescription":"HEREDITARY GYN CA TRGT MRNA SEQ ALYS 12 GENE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0136U","CodeDescription":"ATM MRNA SEQUENCE ANALYSIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0137U","CodeDescription":"PALB2 MRNA SEQUENCE ANALYSIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0138U","CodeDescription":"BRCA1 BRCA2 MRNA SEQUENCE ANALYSIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"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":"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":"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":"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":"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":"0152U","CodeDescription":"NFCT DS MCRB CLL FR DNA UNTRGT NEXT GENRJ SEQ","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0153U","CodeDescription":"ONC BREAST MRNA GENE EXPRESSION PRFL 101 GENES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0154U","CodeDescription":"ONC UROTHELIAL CANCER RNA RT-PCR FGFR3 GENE ALYS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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":"0156U","CodeDescription":"COPY NUMBER SEQUENCE ANALYSIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0157U","CodeDescription":"APC GENE MRNA SEQUENCE ANALYSIS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"0163U","CodeDescription":"ONC CLRCT SCR BIOCHEM ELISA 3 PLSM\/SRM PRTN ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0164T","CodeDescription":"RMVL TOT DISC ARTHRP ANT APPR LMBR EA NTRSPC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0164U","CodeDescription":"GI IBS IA ANTI-CDTB&ANTI-VINCULIN ANTB PLSM ALG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0165T","CodeDescription":"REVJ TOT DISC ARTHRP ANT APPR LMBR EA NTRSPC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":"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":"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":"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":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0170U","CodeDescription":"NEURO ASD RNA NEXT-GNRJ SEQ SALIVA ALG ALYS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"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":"0173U","CodeDescription":"PSYCHIATRY GEN ALYS PNL W\/VARIANT ALYS 14 GENES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0174T","CodeDescription":"CAD CHEST RADIOGRAPH CONCURRENT W\/INTERPRETATION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0174U","CodeDescription":"ONC SOLID TUM MASS SPECTROMETRIC 30 PROTEIN TRGT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0175T","CodeDescription":"CAD CHEST RADIOGRAPH REMOTE FROM PRIMARY INTERPJ","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0175U","CodeDescription":"PSYCHIATRY GEN ALYS PNL W\/VARIANT ALYS 15 GENES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0176U","CodeDescription":"CDTB & VINCULIN IGG ANTIBODIES BY IMMUNOASSAY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0179U","CodeDescription":"ONC NONSM CLL LNG CA CELL FREE DNA ALYS 23 GEN","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0180U","CodeDescription":"ABO GNOTYP ALYS SANGER\/CHAIN SEQ ABO 7 EXONS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"0184T","CodeDescription":"RECTAL TUMOR EXCISION TRANSANAL ENDOSCOPIC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0184U","CodeDescription":"DO GNOTYP GENE ANALYSIS ART4 EXON 2","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"01965","CodeDescription":"ANESTHESIA INCOMPLETE\/MISSED ABORTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"Service related to family planning or related to testing for sexually transmitted infections","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":"01966","CodeDescription":"ANESTHESIA INDUCED ABORTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"Service related to family planning or related to testing for sexually transmitted infections","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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0198T","CodeDescription":"MEAS OCULAR BLOOD FLOW REPEAT IO PRES SAMP W\/I&R","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0200T","CodeDescription":"PERQ SAC AGMNTJ UNI W\/WO BALO\/MCHNL DEV 1 GE NDL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0200U","CodeDescription":"XK GNOTYP GENE ANALYSIS XK EXONS 1-3","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0201T","CodeDescription":"PERQ SAC AGMNTJ BI W\/WO BALO\/MCHNL DEV 2 GE NDLS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0201U","CodeDescription":"YT GNOTYP GENE ANALYSIS ACHE EXON 2","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0202T","CodeDescription":"POST VERT ARTHRPLSTY W\/WO BONE CEMENT 1 LUMB LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0203U","CodeDescription":"AUTOIMMUN IBD MRNA GEN XPRSN PRFL 17 GEN WHL BLD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0204U","CodeDescription":"ONC THYR MRNA GENE XPRSN ALYS 593 GENES FNA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0205U","CodeDescription":"OPH AGE-RELATED MAC DEGENERATION ALYS 3 GEN VRNT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0206U","CodeDescription":"NEUROLOGY ALZHEIMER DISEASE CELL AGGREGATION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0207T","CodeDescription":"EVAC MEIBOMIAN GLNDS AUTO HT& INTMT PRESS UNI","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0207U","CodeDescription":"NEUROLOGY ALZHEIMER DISEASE QUANTITATIVE IMAGING","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0208T","CodeDescription":"PURE TONE AUDIOMETRY AUTOMATED AIR ONLY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0209T","CodeDescription":"PURE TONE AUDIOMETRY AUTOMATED AIR & BONE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0209U","CodeDescription":"CYTOG CONST ALYS INTERROG GEN REG F\/COPY NUMBER","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0210T","CodeDescription":"SPEECH AUDIOMETRY THRESHOLD AUTOMATED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0211T","CodeDescription":"SPEECH AUDIOM THRESHLD AUTO W\/SPEECH RECOGNITION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0211U","CodeDescription":"ONC PAN-TUMOR DNA&RNA NEXT-GENERATION SEQUENCING","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0212T","CodeDescription":"COMPRE AUDIOM THRESHOLD EVAL & SPEECH RECOG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0212U","CodeDescription":"RARE DS WHL GEN&MITOCHDRL DNA SEQ ALYS PROBAND","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0213T","CodeDescription":"NJX DX\/THER PARAVER FCT JT W\/US CER\/THOR 1 LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0213U","CodeDescription":"RARE DS WHL GEN&MITOCHDRL DNA SEQ ALYS EA CMPRTR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0214T","CodeDescription":"NJX DX\/THER PARAVER FCT JT W\/US CER\/THOR 2ND LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0214U","CodeDescription":"RARE DS WHL XOM&MITOCHDRL DNA SEQ ALYS PROBAND","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0215T","CodeDescription":"NJX PARAVERTBRL FACET JT W\/US CER\/THOR 3RD& GT LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0215U","CodeDescription":"RARE DS WHL XOM&MITOCHDRL DNA SEQ ALYS EA CMPRTR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0216T","CodeDescription":"NJX DX\/THER PARAVER FCT JT W\/US LUMB\/SAC 1 LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0216U","CodeDescription":"NEURO INH ATAXIA GENOMIC DNA SEQ ALYS 12 BLD\/SLV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0217T","CodeDescription":"NJX DX\/THER PARAVER FCT JT W\/US LUMB\/SAC LVL 2","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0217U","CodeDescription":"NEURO INH ATAXIA GENOMIC DNA SEQ ALYS 51 BLD\/SLV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0218T","CodeDescription":"NJX PARAVERTBRL FCT JT W\/US LUMB\/SAC 3RD& GT LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0218U","CodeDescription":"NEURO MUSCULAR DYSTROPHY DMD SEQ ALYS BLD\/SALIVA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0219T","CodeDescription":"PLMT POST FACET IMPLANT UNI\/BI W\/IMG & GRFT CERV","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"0220T","CodeDescription":"PLMT POST FACET IMPLT UNI\/BI W\/IMG & GRFT THOR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0220U","CodeDescription":"ONC BRST CA IMAGE ALYS W\/AI ASSMT 12 FEATURES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0221T","CodeDescription":"PLMT POST FACET IMPLT UNI\/BI W\/IMG & GRFT LUMB","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0221U","CodeDescription":"ABO GNOTYP GENE ALYS NEXT-GENERATION SEQ ABO GEN","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"0222T","CodeDescription":"PLACE POSTERIOR INTRAFACET IMPLANT ADDL SEGMENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"0222U","CodeDescription":"RHD&RHCE GNOTYP NEXT-GNRJ SEQ RH PROX PROMOTER","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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 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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 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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":"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 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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":"0313U","CodeDescription":"ONC PNCRS DNA&MRNA NXT-GNRJ SEQ ALYS 74 GEN&CEA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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 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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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1006F","CodeDescription":"OSTEOARTHRITIS SYMPTOMS&FUNCJAL STATUS ASSES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1007F","CodeDescription":"ANTI-INFLAMMATORY\/ANALGESIC SYMPTOM RELIEF ASSES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":10081,"CodeDescription":"INCISION & DRAINAGE PILONIDAL CYST COMPLICATED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1008F","CodeDescription":"GI&RENAL PRESCRIBED\/OTC NSAID RISK FACTORS ASSES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1010F","CodeDescription":"SEVERITY OF ANGINA ASSESSED BY LEVEL OF ACTIVITY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1011F","CodeDescription":"ANGINA PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1012F","CodeDescription":"ANGINA ABSENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"1015F","CodeDescription":"COPD SYMPTOMS ASSESSED\/TOOL COMPLETED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":10180,"CodeDescription":"INCISION & DRAINAGE COMPLEX PO WOUND INFECTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1018F","CodeDescription":"DYSPNEA ASSESSED NOT PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1019F","CodeDescription":"DYSPNEA ASSESSED PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1022F","CodeDescription":"PNEUMOCOCCUS IMMUNIZATION STATUS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1026F","CodeDescription":"CO-MORBID CONDITIONS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1030F","CodeDescription":"INFLUENZA IMMUNIZATION STATUS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1031F","CodeDescription":"SMOKING & 2ND HAND SMOKE IN THE HOME ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1032F","CodeDescription":"CURRENT SMOKER\/EXPOSED TO SECONDHAND SMOKE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1033F","CodeDescription":"TOBACCO NON-SMOKER & NO 2NDHAND SMOKE EXPOSURE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1034F","CodeDescription":"CURRENT TOBACCO SMOKER","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1035F","CodeDescription":"CURRENT SMOKELESS TOBACCO USER","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1036F","CodeDescription":"CURRENT TOBACCO NON-USER CAD CAP COPD PV DM","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1038F","CodeDescription":"PERSISTENT ASTHMA MILD MODERATE OR SEVERE ASTHMA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1039F","CodeDescription":"INTERMITTENT ASTHMA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1040F","CodeDescription":"DSM-5 CRITERIA MDD DOCD AT THE INITIAL EVAL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1050F","CodeDescription":"HISTORY NEW OR CHANGING MOLES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1052F","CodeDescription":"TYPE ANATOMIC LOCATION AND ACTIVITY ALL ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1055F","CodeDescription":"VISUAL FUNCTIONAL STATUS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1060F","CodeDescription":"DOC PERM\/PERSISTENT\/PAROXYSMAL ATRIAL FIB","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1061F","CodeDescription":"DOC ABSENCE PERM&PERSISTENT&PAROXYSM ATRIAL FIB","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1065F","CodeDescription":"ISCHEMIC STROKE SYMP ONSET  LT 3 HRS PRIOR ARRIVAL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1066F","CodeDescription":"ISCHEMIC STROKE SYMP ONSET GE 3 HRS PRIOR ARRIVA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1070F","CodeDescription":"ALARM SYMPTOMS ASSESSED NONE PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1071F","CodeDescription":"ALARM SYMPTOMS ASSESSED 1 GE PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1090F","CodeDescription":"PRESENCE\/ABSENCE URINARY INCONTINENCE ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1091F","CodeDescription":"URINE INCONTINENCE CHARACTERIZED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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":11004,"CodeDescription":"DBRDMT SKN SUBQ T\/M\/F NECRO INFCTJ GENT&PR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1100F","CodeDescription":"PT FALLS ASSESS DOCD 2 GE FALLS\/FALL W\/INJURY\/YR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11010,"CodeDescription":"DBRDMT W\/RMVL FM FX&\/DISLC SKIN&SUBQ TISSUS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1101F","CodeDescription":"PT FALLS ASSESS DOCD W\/O FALL\/INJURY PAST YEAR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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":"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":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":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":"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":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":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":"1110F","CodeDescription":"PT DISCHARGE INPT FACILITY WITHIN LAST 60 DAYS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1111F","CodeDescription":"DISCHRG MEDS RECONCILED W\/CURRENT MED LIST","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1116F","CodeDescription":"AURICULAR\/PERIAURICULAR PAIN ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1118F","CodeDescription":"GERD SYMPTOMS ASSESSED AFTER 12 MONTHS THERAPY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1119F","CodeDescription":"INITIAL EVALUATION FOR CONDITION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11200,"CodeDescription":"REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW\/15","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1121F","CodeDescription":"SUBSEQUENT EVALUATION CONDITION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1123F","CodeDescription":"ADV CARE PLN TLKD & ALT DCSN MAKER DOCD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1124F","CodeDescription":"ADV CARE PLN\/ NO ALT DCSN MKR DOCD OR REFUSAL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1125F","CodeDescription":"PAIN SEVERITY QUANTIFIED PAIN PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1126F","CodeDescription":"PAIN SEVERITY QUANTIFIED NO PAIN PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1127F","CodeDescription":"NEW EPISODE FOR CONDITION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1128F","CodeDescription":"SUBS EPISODE FOR CONDITION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":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 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":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","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":"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":11302,"CodeDescription":"SHVG SKN 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, and UCSF members going out of their medical group","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":"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":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11303,"CodeDescription":"SHVG SKIN LESION 1 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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":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":"1130F","CodeDescription":"BK PAIN & FXN ASSESSED CERTAIN ASPECTS OF CARE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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":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":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":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":"1134F","CodeDescription":"EPISODE BACK PAIN LASTING SIX WEEKS LE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1135F","CodeDescription":"EPISODE BACK PAIN LASTING GT SIX WEEKS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1136F","CodeDescription":"EPISODE BACK PAIN LASTING 12 WEEKS LE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1137F","CodeDescription":"EPISODE BACK PAIN LASTING GT 12 WKS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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":11402,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 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":11402,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 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":11402,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L 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":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 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":"Authorization Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical 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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, 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":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":11406,"CodeDescription":"EXC B9 LESION MRGN XCP SK TG T\/A\/L GT 4.0 CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT 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(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 GROUP \/ NONPAR","PriorAuthReq":"YES"},{"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, UCSF, and SDN members going out of 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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":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":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 \/ 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(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 \/ 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 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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, 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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1150F","CodeDescription":"DOC PT W\/SUBSTANTIAL RISK DEATH WITHIN 1 YEAR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1151F","CodeDescription":"DOC PT W\/O SUBSTANTIAL RISK DEATH WITHIN 1 YEAR","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1152F","CodeDescription":"DOC ADVANCED DISEASE DX CARE GOALS COMFORT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1153F","CodeDescription":"DOC ADVANCED DISEASE DX CARE GOALS W\/O COMFORT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1157F","CodeDescription":"ADVNC CARE PLAN OR EQV LGL DOC IN MED RCRD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1158F","CodeDescription":"ADVNC CARE PLANNING TLK DOCD IN MED RCRD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1159F","CodeDescription":"MEDICATION LIST DOCUMENTED IN MEDICAL RECORD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11600,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 0.5 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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 Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"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 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":11604,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 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":11604,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 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":11604,"CodeDescription":"EXCISION MAL LESION TRUNK\/ARM\/LEG 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":11606,"CodeDescription":"EXCISION MALIGNANT LESION TRUNK\/ARM\/LEG  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":11606,"CodeDescription":"EXCISION MALIGNANT LESION TRUNK\/ARM\/LEG  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":11606,"CodeDescription":"EXCISION MALIGNANT LESION TRUNK\/ARM\/LEG  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":11606,"CodeDescription":"EXCISION MALIGNANT LESION TRUNK\/ARM\/LEG  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":11606,"CodeDescription":"EXCISION MALIGNANT LESION TRUNK\/ARM\/LEG  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":"1160F","CodeDescription":"RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11620,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11620,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11620,"CodeDescription":"EXCISION MALIGNANT LESION 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":11620,"CodeDescription":"EXCISION MALIGNANT LESION 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 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 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":11621,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11621,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11621,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11621,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11621,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11622,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11622,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11622,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11622,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11622,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11623,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11623,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11623,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11623,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11623,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11624,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11624,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11624,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11624,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11624,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11626,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11626,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11626,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11626,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11626,"CodeDescription":"EXCISION MALIGNANT LESION S\/N\/H\/F\/G 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":11640,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11640,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11640,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11640,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11640,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11641,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11641,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11641,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11641,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11641,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11642,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11642,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 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":11642,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 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":11642,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 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":11642,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/L 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":11643,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11643,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11643,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11643,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11643,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11644,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11644,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11644,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11644,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11644,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11646,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11646,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11646,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11646,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":11646,"CodeDescription":"EXCISION MALIGNANT LESION F\/E\/E\/N\/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":"1170F","CodeDescription":"FUNCTIONAL STATUS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11719,"CodeDescription":"TRIMMING NONDYSTROPHIC NAILS ANY NUMBER","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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":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":"1175F","CodeDescription":"FUNCTIONAL STATUS DEMENTIA ASSESS RESULTS RVWD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11760,"CodeDescription":"REPAIR NAIL BED","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1180F","CodeDescription":"THROMBOEMBOLIC RISK ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1181F","CodeDescription":"NEUROPSYCHIATRIC SYMPTS ASSESSED RESULTS REVIEWD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1182F","CodeDescription":"NEUROPSYCHIATRIC SYMPTOMS ONE OR MORE PRESENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1183F","CodeDescription":"NEUROPSYCHIATRIC SYMPTOMS ABSENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":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":11920,"CodeDescription":"TATTOOING INCL MICROPIGMENTATION 6.0 CM LE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11921,"CodeDescription":"TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11922,"CodeDescription":"TATTOOING INCL MICROPIGMENTATION EA 20.0 CM","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11950,"CodeDescription":"SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC LE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11951,"CodeDescription":"SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11952,"CodeDescription":"SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11954,"CodeDescription":"SUBCUTANEOUS INJECTION FILLING MATRL GT 10.0 CC","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":11960,"CodeDescription":"INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11976,"CodeDescription":"REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"Service related to family planning or related to testing for sexually transmitted infections","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":11980,"CodeDescription":"SUBCUTANEOUS HORMONE PELLET IMPLANTATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":11981,"CodeDescription":"INSERTION DRUG DELIVERY IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Never Required (PAR & NON-PAR)","BenefitDetail":"Service related to family planning or related to testing for sexually transmitted infections","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"NO"},{"Code":11982,"CodeDescription":"REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT","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":11982,"CodeDescription":"REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":11982,"CodeDescription":"REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT","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":11982,"CodeDescription":"REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT","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":11982,"CodeDescription":"REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT","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":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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1200F","CodeDescription":"SEIZURE TYPE FREQUENCY DOCUMENTED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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 group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"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, UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":12041,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 2.5CM 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":12041,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 2.5CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":12041,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 2.5CM 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":12042,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 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":12042,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 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":12042,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 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":12042,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 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":12042,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 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":12044,"CodeDescription":"REPAIR INTERMEDIATE N\/H\/F\/XTRNL GENT 7.6-12.5CM","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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(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":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":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":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":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":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":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":"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":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":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":"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":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":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":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":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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1400F","CodeDescription":"PARKINSON DISEASE DIAGNOSIS REVIEWED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1450F","CodeDescription":"SYMPTOMS IMPROVED\/CONSIST W\/TXMNT GOAL ASSESSMNT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1451F","CodeDescription":"SYMPTOMS SHOW CLIN IMPRTNT DROP SINCE ASSESSMENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1460F","CodeDescription":"QUALIFYING CARD EVENT\/DIAGNOSIS PRIOR 12 MONTHS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1461F","CodeDescription":"NO QUAL CARD EVENT\/DIAG IN PREVIOUS 12 MONTHS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1490F","CodeDescription":"DEMENTIA SEVERITY CLASSIFIED MILD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1493F","CodeDescription":"DEMENTIA SEVERITY CLASSIFIED SEVERE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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":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":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":"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":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":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":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":"1500F","CodeDescription":"SYMP&SIGN DISTAL SYMM POLYNEUROPATHY REVWD&DOCD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1501F","CodeDescription":"NOT INITIAL EVALUATION FOR CONDITION","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1502F","CodeDescription":"PT QUERIED RE PAIN W\/FUNC USING RELIABLE INSTRM","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"1503F","CodeDescription":"PT QUERIED RE SYMP RESPIRATORY INSUFFICIENCY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15040,"CodeDescription":"HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM LE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1504F","CodeDescription":"PATIENT HAS RESPIRATORY INSUFFICIENCY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15050,"CodeDescription":"PINCH GRAFT 1\/MLT SM ULCER TIP\/OTH AREA 2CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"1505F","CodeDescription":"PATIENT DOES NOT HAVE RESPIRATORY INSUFFICIENCY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15775,"CodeDescription":"PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15776,"CodeDescription":"PUNCH GRAFT HAIR TRANSPLANT GT 15 PUNCH GRAFTS","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15778,"CodeDescription":"IMPL ABSRB MESH\/PRSTH DLYD CLSR DFCT INFCTJ\/TRMA","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15819,"CodeDescription":"CERVICOPLASTY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15820,"CodeDescription":"BLEPHAROPLASTY LOWER EYELID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15824,"CodeDescription":"RHYTIDECTOMY FOREHEAD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15825,"CodeDescription":"RHYTIDECTOMY NECK W\/PLATYSMAL TIGHTENING","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15826,"CodeDescription":"RHYTIDECTOMY GLABELLAR FROWN LINES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15828,"CodeDescription":"RHYTIDECTOMY CHEEK CHIN & NECK","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15829,"CodeDescription":"RHYTIDECTOMY SMAS FLAP","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15830,"CodeDescription":"EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15832,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE THIGH","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15833,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE LEG","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15834,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE HIP","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15835,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE BUTTOCK","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15836,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE ARM","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15837,"CodeDescription":"EXC EXCESSIVE SKIN &SUBQ TISSUE FOREARM\/HAND","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15838,"CodeDescription":"EXC EXCSV SKIN & SUBQ TISSUE SUBMENTAL FAT PAD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15839,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE OTHER AREA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15840,"CodeDescription":"GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15847,"CodeDescription":"EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":15852,"CodeDescription":"DRESSING CHANGE UNDER ANESTHESIA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15853,"CodeDescription":"REMOVAL SUTURES\/STAPLES NOT REQUIRING ANESTHESIA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15854,"CodeDescription":"REMOVAL SUTURES&STAPLES NOT REQUIRING ANESTHESIA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15860,"CodeDescription":"IV INJECTION TEST VASCULAR FLOW FLAP\/GRAFT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15876,"CodeDescription":"SUCTION ASSISTED LIPECTOMY HEAD & NECK","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15877,"CodeDescription":"SUCTION ASSISTED LIPECTOMY TRUNK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":15878,"CodeDescription":"SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15879,"CodeDescription":"SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":15920,"CodeDescription":"EXC COCCYGEAL PR ULC W\/COCCYGECTOMY W\/PRIM SUTR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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":"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":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":17263,"CodeDescription":"DESTRUCTION MAL LESION TRUNK\/ARM\/LEG 2.1-3.0CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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":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":19020,"CodeDescription":"MASTOTOMY W\/EXPLORATION\/DRAINAGE ABSCESS DEEP","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":19085,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION MAGNETIC RES 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":19085,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION MAGNETIC RES 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":19085,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION MAGNETIC RES 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":19085,"CodeDescription":"BX BREAST W\/DEVICE 1ST LESION MAGNETIC RES GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","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":"No Authorization Required (PAR)","BenefitDetail":"SDN member at any SFHP Network Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19086,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION MAGNET RES 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":19086,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION MAGNET RES GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19086,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION MAGNET RES 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":19086,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION MAGNET RES 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":19086,"CodeDescription":"BX BREAST W\/DEVICE ADDL LESION MAGNET RES 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":19100,"CodeDescription":"BX BREAST NEEDLE CORE W\/O IMAGING GUIDANCE SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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":19105,"CodeDescription":"ABLTJ CRYOSURGICAL W\/US GID EA FIBROADENOMA","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":19110,"CodeDescription":"NIPPLE EXPLORATION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":19125,"CodeDescription":"EXC BREAST LES PREOP PLMT RAD MARKER OPEN 1 LES","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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 Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"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 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":19281,"CodeDescription":"PERQ DEVICE PLACEMENT BREAST LOC 1ST LES 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":19281,"CodeDescription":"PERQ DEVICE PLACEMENT BREAST LOC 1ST LES 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":19281,"CodeDescription":"PERQ DEVICE PLACEMENT BREAST LOC 1ST LES 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":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":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":19283,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC 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":19283,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC GDNCE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19283,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC 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 Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19283,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC 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":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":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":19285,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG","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":19285,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","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":"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 Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19285,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG","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":"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":"No Authorization Required (PAR)","BenefitDetail":"SFN or CLN member at ZSFGH","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":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","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":"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 Required (NON-PAR)","BenefitDetail":"SFN, CLN, and UCSF members going out of their medical group","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19287,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO MR 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":19288,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR 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":19288,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR GUID","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":19288,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR 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":19288,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR 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":19288,"CodeDescription":"PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR 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":19294,"CodeDescription":"PREP TUMOR CAVITY IORT W\/PARTIAL MASTECTOMY","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":19355,"CodeDescription":"CORRECTION INVERTED NIPPLES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":19357,"CodeDescription":"TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"2000F","CodeDescription":"BLOOD PRESSURE MEASURED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2001F","CodeDescription":"WEIGHT RECORDED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2002F","CodeDescription":"CLINICAL SIGNS VOLUME OVERLOAD ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2004F","CodeDescription":"INITIAL EXAMINATION INVOLVED JOINTS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":20100,"CodeDescription":"EXPLORATION PENETRATING WOUND SPX NECK","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"2010F","CodeDescription":"VITAL SIGNS RECORDED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2014F","CodeDescription":"MENTAL STATUS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":20150,"CodeDescription":"EXCISION EPIPHYSEAL BAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"2015F","CodeDescription":"ASTHMA IMPAIRMENT ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2016F","CodeDescription":"ASTHMA RISK ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2018F","CodeDescription":"HYDRATION STATUS ASSESSED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2019F","CodeDescription":"DILATED MACULAR EXAM PERFORMED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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":"2020F","CodeDescription":"DILATED FUNDUS EVALUATION PERFORMED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2021F","CodeDescription":"DILATED MACULAR OR FUNDUS EXAM PERFORMED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":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":"2022F","CodeDescription":"DILATED RETINAL EXAM W\/EVIDENCE OF RETINOPATHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2023F","CodeDescription":"DILATED RETINAL EXAM W\/O EVIDENCE OF RETINOPATHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":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":"2024F","CodeDescription":"7 STANDARD FLD RETINAL PHOTO W\/EVC RTNOPTHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":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":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":"2025F","CodeDescription":"7 STANDARD FLD RETINAL PHOTO W\/O EVC RTNOPTHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2026F","CodeDescription":"EYE IMG VALID MATCH DX 7 STND FLD W\/EVC RTNOPTHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2027F","CodeDescription":"OPTIC NERVE HEAD EVALUATION PERFORMED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2028F","CodeDescription":"FOOT EXAMINATION PERFORMED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2029F","CodeDescription":"COMPLETE PHYSICAL SKIN EXAM PERFORMED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2030F","CodeDescription":"HYDRATION STATUS DOCD NORMALLY HYDRATED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2031F","CodeDescription":"HYDRATION STATUS DOCUMENTED DEHYDRATED","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2033F","CodeDescription":"EYE IMG VLD MTCH DX 7 STND FLD W\/O EVC RTNOPTHY","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Service or code that is not in Medi-Cal's fee schedule","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2035F","CodeDescription":"TYMPANIC MEMBRANE MOBILITY ASSESS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2040F","CodeDescription":"PHYS EXAM ON DATE OF INIT VST FOR LBP DONE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":"2044F","CodeDescription":"DOC MNTL HLTH ASSES PRIOR INTVN BACK PAIN 6WKS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":20500,"CodeDescription":"INJECTION SINUS TRACT THERAPEUTIC SEPARATE PROC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":"2050F","CodeDescription":"WOUND CHARACTERISTICS DOCD PRIOR DEBRIDEMENT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":20520,"CodeDescription":"REMOVAL FOREIGN BODY MUSCLE\/TENDON SHEATH SIMPLE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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":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":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":"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":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":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":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":20555,"CodeDescription":"PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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":"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":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":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":"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":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":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":"2060F","CodeDescription":"PT INTRVWD BY EVAL CLINICIAN  LT \/DATE DIAG MDD","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"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":"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":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 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UCSF, and SDN members going out of the SFHP Network","ProviderNetworkStatus":"OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":20696,"CodeDescription":"XTRNL FIXJ W\/STEREOTACTIC ADJUSTMENT 1ST & SUBQ","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":20696,"CodeDescription":"XTRNL FIXJ W\/STEREOTACTIC ADJUSTMENT 1ST & SUBQ","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20696,"CodeDescription":"XTRNL FIXJ W\/STEREOTACTIC ADJUSTMENT 1ST & SUBQ","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":20697,"CodeDescription":"XTRNL FIXJ W\/STRTCTC ADJUSTMENT EXCHANGE STRUT","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":20697,"CodeDescription":"XTRNL FIXJ W\/STRTCTC ADJUSTMENT EXCHANGE STRUT","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":20697,"CodeDescription":"XTRNL FIXJ W\/STRTCTC ADJUSTMENT EXCHANGE STRUT","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":20697,"CodeDescription":"XTRNL FIXJ W\/STRTCTC ADJUSTMENT EXCHANGE STRUT","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"No Authorization Required (PAR)","BenefitDetail":"UCSF member at UCSF","ProviderNetworkStatus":"IN MEDICAL GROUP","PriorAuthReq":"NO"},{"Code":20697,"CodeDescription":"XTRNL FIXJ W\/STRTCTC ADJUSTMENT EXCHANGE STRUT","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":20700,"CodeDescription":"MANUAL PREP AND INSERTION DEEP DRUG DELIVERY DEV","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":20704,"CodeDescription":"MANUAL PREP&INSJ I-ARTIC DRUG DELIVERY DEVICE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21076,"CodeDescription":"IMPRESSION&PREPARATION SURG OBTURATOR PROSTHES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21077,"CodeDescription":"IMPRESSION & PREPARATION ORBITAL PROSTHESIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21079,"CodeDescription":"IMPRESSION & PREPARATION INTERIM OBTURATOR PROST","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21080,"CodeDescription":"IMPRESSION & PREPJ DEFINITIVE OBTURATOR PROSTHES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21081,"CodeDescription":"IMPRESSION & PREPJ MANDIBULAR RESECTION PROSTHES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21082,"CodeDescription":"IMPRESSION & PREPJ PALATAL AUGMENTATION PROSTHES","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21083,"CodeDescription":"IMPRESSION & PREPARATION PALATAL LIFT PROSTHESIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21084,"CodeDescription":"IMPRESSION & PREPARATION SPEECH AID PROSTHESIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21085,"CodeDescription":"IMPRESSION & PREPARATION ORAL SURGICAL SPLINT","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21086,"CodeDescription":"IMPRESSION & PREPARATION AURICULAR PROSTHESIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21087,"CodeDescription":"IMPRESSION & PREPARATION NASAL PROSTHESIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21088,"CodeDescription":"IMPRESSION & PREPARATION FACIAL PROSTHESIS","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21089,"CodeDescription":"UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21100,"CodeDescription":"APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":21125,"CodeDescription":"AGMNTJ MNDBLR BODY\/ANGLE PROSTHETIC MATERIAL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":21127,"CodeDescription":"AGMNTJ MNDBLR BDY\/ANGL W\/GRF ONLAY\/INTERPOSAL","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":21930,"CodeDescription":"EXCISION TUMOR SOFT TISSUE BACK\/FLANK SUBQ  LT 3CM","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22526,"CodeDescription":"PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LEVEL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":22527,"CodeDescription":"PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL","BenefitPlan":"","BenefitHeader":"Authorization always required","BenefitDetail":"Excluded services","ProviderNetworkStatus":"","PriorAuthReq":""},{"Code":22532,"CodeDescription":"ARTHRODESIS LATERAL EXTRACAVITARY THORACIC","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"SFN, CLN, UCSF and SDN members going to any Provider or Facility","ProviderNetworkStatus":"IN MEDICAL GROUP \/ OUT OF MEDICAL GROUP \/ NONPAR","PriorAuthReq":"YES"},{"Code":22860,"CodeDescription":"TOTAL DISC ARTHRP ANT SECOND INTERSPACE LUMBAR","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":23071,"CodeDescription":"EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3 CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":24071,"CodeDescription":"EXC TUMOR SOFT TISSUE UPPER ARM\/ELBOW SUBQ 3CM GE","BenefitPlan":"MEDI-CAL (MC) BENEFIT PLAN","BenefitHeader":"Authorization Always Required (PAR)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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)","BenefitDetail":"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":"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":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":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":"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":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":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":"SF