Effective January 1, 2026: New Prior Authorization Requirement for Certain Procedures

Date: 10/01/25

Please Note: This article has been updated as of 12/10/2025.

Superior HealthPlan will require prior authorization for certain procedures listed below for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter from Superior HealthPlan and Wellcare By Allwell.

Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided, as a result, the following code update is effective on January 1, 2026. See below for the services and applicable product to this new requirement.

Applicable Products: Medicaid and CHIP

Surgical Procedures and Pathology

CPT Code	CPT Description	Criteria
15734	MUSCL MYOCUT/FASCIOCUT FLAP; TRUNK	Change Healthcare’s InterQual criteria, proprietary, but available upon request
19301	PARTIAL MASTECTOMY
37243	VASC EMBOLIZE/OCCLUDE ORGAN
49329	LAPARO PROC, ABDM/PER/OMENT
49505	PRP I/HERN INIT REDUC >5 YR
49591	RPR AA HERNIA 1ST < 3 CM REDUCIBLE
49593	RPR AA HERNIA 1ST 3-10 CM REDUCIBLE
49595	RPR AA HERNIA 1ST > 10 CM REDUCIBLE
49650	LAP ING HERNIA REPAIR INIT
54360	PENIS PLASTIC SURGERY
58571	TLH W/T/O 250 G OR LESS
58573	TLH W/T/O UTERUS OVER 250 G
58661	LAPAROSCOPY, REMOVE ADNEXA
58662	LAPAROSCOPY W/FULGURATION OR EXCISION OF LESIONS OF OVARY
64999	NERVOUS SYSTEM SURGERY
88377	M/PHMTRC ALYS ISHQUANT/SEMIQ

Applicable Products: Medicaid and CHIP

Skin Substitutes

CPT Code

CPT Description

Criteria

Q4195

PURAPLY PER SQ CM

CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds

For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Q4196

PURAPLY AM PER SQ CM

Appliable Products: Medicaid and CHIP

Behavioral Health: Prior Authorization required for 31 or more visits in a calendar year

CPT Code	CPT Description	Criteria
90847	FAMILY PSYTX W/PT 50 MIN	Change Healthcare’s InterQual criteria, proprietary, but available upon request.
90853	GROUP PSYCHOTHERAPY

Applicable Products: Medicaid and CHIP

Genetic Testing

CPT Code

CPT Description

Criteria

0340U

Should be requested under the appropriate CPT code.

ONC PAN CANCER ANALYSIS MRD FROM PLASMA

Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.

Applicable Products: Ambetter from Superior HealthPlan

Surgical Procedures

CPT Code	CPT Description	Criteria
28300	INCISION OF HEEL BONE	Change Healthcare’s InterQual criteria, proprietary, but available upon request
28308	INCISION OF METATARSAL
43281	LAP PARAESOPHAG HERN REPAIR
43282	LAP PARAESOPH HER RPR W/MESH
49329	LAPARO PROC, ABDM/PER/OMENT
55866	LAPARO RADICAL PROSTATECTOMY
28285	CORRECT HAMMERTOE
28299	CORRECTION HALLUX VALGUS

Applicable Products: Ambetter from Superior HealthPlan

Genetic Testing

CPT Code	CPT Description	Criteria
81599	UNLISTED MAAA	Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.

Applicable Products: Ambetter from Superior HealthPlan

Pharmacy

CPT Code	CPT Description	Criteria
J3240	INJ THYROTROPIN .9 MG PROV 1.1 VIAL	Clinical Policy For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage.
Q0138	FERUMOXYTOL, NON-ESRD
Q0139	FERUMOXYTOL, ESRD USE
Q5107	INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG
Q5108	INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG

Applicable Products: Wellcare By Allwell (Medicare)

Service Category

Services

Procedure Codes

Transportation Services

Medical Transportation

A0431, A0436

Skin Substitutes & Wound Dressings

C9358, C9360, C9363, Q4111, Q4115, Q4117, Q4118, Q4125, Q4134, Q4135, Q4136, Q4139, Q4145, Q4162, Q4165, Q4166, Q4167, Q4168, Q4170, Q4171, Q4174, Q4176, Q4177, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4214, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248, Q4251,Q4252, Q4253

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage and Medicare Prior-Authorization Clinical Policies webpage.

Prior to updates, the policies were approved for use by the Utilization Management Committee and Medicare Quality Committee.

For questions or additional information, regarding Medicaid/CHIP and Ambetter contact Superior’s Prior Authorization department at 1-800-218-7508.

For questions or additional information, regarding Medicare please contact Wellcare By Allwell Provider Services at HMO: 1-800-977-7522 and DSNP: 1-877-935-8023.