Effective 4/1/26: New Prior Authorization Requirement for Certain Procedure Codes
Date: 12/23/25
Effective April 1, 2026, Superior HealthPlan will require prior authorization for certain procedure codes for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter from Superior HealthPlan members.
Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following procedure code update is effective on April 1, 2026, and is noted below with applicable product line.
Medicaid and CHIP members
Pharmacy
CPT Code | Description | Criteria |
Q5111 | INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR 0.5 MG | Clinical Policy For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage.
|
Q5114 | INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG | |
Q5116 | INJECTION TRASTUZUMAB-QYYP BIOSIMILAR 10 MG | |
J0878 | INJECTION DAPTOMYCIN 1 MG | |
Q5106 | INJ EPOETIN ALFA BIOSIMILAR 1000 U | |
Q5107 | INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG | |
Q5113 | INJECTION TRASTUZUMAB-PKRB BIOSIMILAR 10 MG | |
Q5117 | INJECTION TRASTUZUMAB-ANNS BIOSIMILAR 10 MG | |
Q5118 | INJECTION BEVACIZUMAB-BVZR BIOSIMILAR 10 MG | |
Q5120 | INJ PEGFILGRASTIM-BMEZ BIOSIMLR ZIEXTENZO 0.5 MG | |
Q5122 | INJECTION PEGFILGRASTIM APGF BIOSIMILAR 0.5 MG | |
Q5126 | INJ BEVACIZUMAB-MALY BIOSIMILAR (ALYMSYS) 10 MG | |
Q5127 | INJECTION PEG-FPGK STIMUFEND BIOSIMILAR 0.5 MG | |
Q5130 | INJECTION PEG-PBBK FYLNETRA BIOSIMILAR 0.5 MG |
Surgical Procedures: Pre-authorization is required for all providers after 12 visits per calendar year.
CPT Code | Description | Criteria |
11043 | DEB MUSC/FASCIA 20 SQ CM/< | Change Healthcare’s InterQual criteria, proprietary, but available upon request. |
Surgical Procedures: Pre-authorization is required if billed with diagnosis of gender dysphoria. For all others, pre-authorization is required for non-participating providers only.
CPT Code | Description | Criteria |
|---|---|---|
15100 | SKIN SPLT GRFT TRNK/ARM/LEG | TX.CP.MP.595 Gender Transitioning and Gender Reassignment Procedures and Treatments
|
15101 | SKIN SPLT GRFT T/A/L ADD-ON | |
15120 | SKN SPLT A-GRFT FAC/NCK/HF/G | |
54520
| ORCHIECTOMY SIMPL W/WO TESTICULAR PROSTH | |
58260 | VAG HYST UTERUS 250 GRAMS OR LESS; | |
58262
| VAG HYST INCLUDING T/O | |
58550 | LAPARO-ASST VAG HYSTERECTOMY | |
58552 | LAPARO-VAG HYST INCL T/O | |
58553 | LAPARO-VAG HYST COMPLEX | |
58554 | LAPARO-VAG HYST W/T/O COMPL |
Breast Procedure: Pre-authorization is not required if billed with breast cancer diagnosis. If billed with any other diagnosis, pre-authorization will be required for all providers.
CPT Code | Description | Criteria |
|---|---|---|
19303 | MASTECTOMY, SIMPLE, COMPLETE | Change Healthcare’s InterQual criteria, proprietary, but available upon request. |
Joint and Surgical Procedures
CPT Code | Description | Criteria |
|---|---|---|
15271 | SKIN SUB GRAFT TRNK/ARM/LEG | Change Healthcare’s InterQual criteria, proprietary, but available upon request.
|
15274 | SKN SUB GRFT T/A/L CHILD ADD | |
15275 | SKIN SUB GRAFT FACE/NK/HF/G | |
15276 | SKIN SUB GRAFT F/N/HF/G ADDL | |
15736 | MUSCL MYOCUT/FASCIOCUT FLAP; UP EXTREM | |
15738 | MUSCL MYOCUT/FASCIOCUT FLAP; LOWER EXTREM | |
21235 | GFT; EAR CARTILAGE AUTOGEN NOSE/EAR | |
22830 | EXPLOR SPINAL FUSION | |
22848 | PELVIC FIXATION OTHER THAN SACRUM | |
22849 | REINSERTION SPINAL FIXA DEVICE | |
25447 | ARTHROPLAS INTERPOSIT-INTERCARP/CARPOMETACARP JT | |
27702 | ARTHROPLASTY ANK; W/IMPLNT (TOT ANK) | |
28285 | CORRECT HAMMERTOE | |
28296 | CORRECTION HALLUX VALGUS | |
29999 | UNLISTED PROCEDURE ARTHROSCOPY | |
58545 | LAP MYOMCT;1-4 MYOM 250 GM/<&/SURFC | |
63016 | REMOVE SPINE LAMINA >2 THRC | |
63200 | LAMINECTOMY W/RELEASE TETHERED CORD LUMBAR | |
64561 | IMPLANT NEUROELECTRODES | |
64582 | OPEN IMPLTJ HPGLSL NRV NSTIM RA PG AND RESPIR SENSOR | |
64628 | THERMAL DSTRJ INTRAOSSEOUS BVN 1ST 2 LMBR/SAC | |
64629 | THERMAL DSTRJ INTRAOSSEOUS BVN EA ADDL LMBR/SAC | |
99183 | HYPERBARIC OXYGEN THERAPY | |
99199 | UNLISTED SPECIAL SERV/REPORT | |
G0277 | HBOT, FULL BODY CHAMBER, 30M |
Joint Injections: Authorization is required unless performed on the same day as an approved or paid surgery.
CPT Code | Description | Criteria |
|---|---|---|
64430 | INJECTION AA AND /STRD PUDENDAL NERVE | Change Healthcare’s InterQual criteria, proprietary, but available upon request. |
64445 | INJECTION AA AND /STRD SCIATIC NERVE |
Ambulatory and Long-Term Electroencephalogram (EEG)
CPT Code | Description | Criteria |
|---|---|---|
95700 | EEG CONT REC W/VID EEG TECH | Medical Necessity Review Criteria: Change Healthcare’s InterQual criteria, proprietary, but available upon request.
|
95712 | VEEG 2-12 HR INTMT MNTR | |
95713 | VEEG 2-12 HR CONT MNTR | |
95714 | VEEG EA 12-26 HR UNMNTR | |
95715 | VEEG EA 12-26HR INTMT MNTR | |
95716 | VEEG BY TECH EA INCR 12-26 HR CONT R-T MNTR | |
95718 | EEG PHYS/QHP 2-12 HR WITH VEEG | |
95720 | EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG | |
95721 | EEG PHY/QHP>36<60 HR W/O VID | |
95722 | EEG PHY/QHP>36<60 HR W/VEEG | |
95723 | EEG PHY/QHP>60<84 HR W/O VID | |
95724 | EEG PHY/QHP>60<84 HR W/VEEG | |
95725 | EEG PHY/QHP>84 HR W/O VID | |
95726 | EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG |
Ambetter from Superior HealthPlan members
Genetic and Molecular Testing
CPT Code | Description | Criteria |
|---|---|---|
0002M | LIVER DIS 10 ASSAYS W/ASH | Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.
|
0175U | PSYCHIATRY GEN ALYS PNL W/VARIANT ALYS 15 GENES | |
0175U | PSYCHIATRY GEN ALYS PNL W/VARIANT ALYS 15 GENES | |
0347U | RX METAB/PCX DNA 16 GENE VRNT ALYS AND REPRTD PHNT | |
0348U | RX METAB/PCX DNA 25 GENE VRNT ALYS AND REPRTD PHNT | |
0350U | RX METAB/PCX DNA 27 GENE VRNT ALYS AND REPRTD PHNT | |
0173U | PSYCHIATRY GEN ALYS PNL W/VARIANT ALYS 14 GENES | |
0033U | HTR2A HTR2C GENES | |
0434U | RX METAB ADVRS RX RXN AND RSPSE VARIANT ALYS 25 GEN | |
0423U | PSYC GENOMIC ALYS PNL VRNT ALYS 26 GEN BUCC SWAB | |
0419U | NEUROPSYCHIATRY GEN SEQ ALYS PNL VRNT ALY 13 GEN | |
0392U | RX METAB GEN-RX IA VRNT ALYS 16 GENES CYP2D6 | |
0437U | PSYC ANXIETY DO MRNA GEN XPRSN PRFL RNA 15 BMRK |
Joint and Surgical Procedures
CPT Code | Description | Criteria |
|---|---|---|
25111 | REMOVE WRIST TENDON LESION | Change Healthcare’s InterQual criteria, proprietary, but available upon request.
|
29848 | ENDO WRIST SURG-RELEAS TRANSVERSE CARPAL LIGAMNT | |
37799 | UNLISTED PROC VASCULAR SURG | |
64495 | INJ PARAVERT F JNT L/S 3 LEV |
Durable Medical Equipment
CPT Code | Description | Criteria |
|---|---|---|
A9276 | DISPOSABLE SENSOR, CGM SYS | Change Healthcare’s InterQual criteria, proprietary, but available upon request. |
Behavioral Health
CPT Code | Description | Criteria |
|---|---|---|
H0017 | BHVAL HEALTH RES W/O ROOMANDBD-DIEM | Mental Health Diagnosis: Change Healthcare’s InterQual criteria, proprietary, but available upon request.
Substance use disorder diagnosis: Change Healthcare’s InterQual ASAM Navigator criteria, proprietary, but available upon request. |
Pharmacy
CPT Code | Description | Criteria |
|---|---|---|
Q5101 | INJECTION, ZARXIO | Clinical Policy
For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage.
|
Q5105 | INJ EPOETIN ALFA BIOSIMILAR 100 U | |
Q5106 | INJ EPOETIN ALFA BIOSIMILAR 1000 U | |
Q5108 | INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG | |
Q5111 | INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR 0.5 MG | |
Q5114 | INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG | |
Q5116 | INJECTION TRASTUZUMAB-QYYP BIOSIMILAR 10 MG |
To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.
For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.