Effective 11/1/26: New Prior Authorization Requirement for Certain Procedures

Date: 07/22/26

Superior HealthPlan will require prior authorization for certain procedures for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Ambetter from Superior HealthPlan and Ambetter Health Solutions 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 November 1, 2026, according to the products listed below.

Medicaid and CHIP Members:

Service Category	Procedure Code	Description	Criteria
Genitourinary Procedures	55899	GENITAL SURGERY PROCEDURE	Change Healthcare’s InterQual criteria, proprietary, but available upon request.
Physician Services	91299	GASTROENTEROLOGY PROCEDURE
Genetic Testing	0493U	TRNSPLJ MED QUANTIFICATION DD-CFDNA NGS PLASMA (Prospera)	Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.

Medicaid, CHIP and Ambetter Health: Members of all ages

Service Category	Procedure Code	Description	Criteria
Sleep Medicine	95811	POLYSOM 6/>YRS CPAP 4/> PARM	Change Healthcare’s InterQual criteria, proprietary, but available upon request.
Genetic Testing	0540U	TRNSPLJ MEDICINE QUAN DD-CFDNA NGS ALYS PLASMA (AlloSure)	Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.
	81162	BRCA1 BRCA2 GENE ALYS FULL SEQ FULL DUP/DEL ALYS
	81523	ONC BRST MRNA NEXT GNRJ SEQ GEN XPRSN 70 CNT&31

Ambetter Health: Members of all ages

Service Category	Procedure Code	Description	Criteria
Sleep Medicine	95810	POLYSOM 6/> YRS 4/> PARAM	Change Healthcare’s InterQual criteria, proprietary, but available upon request.
Genetic Testing	0632U	RBC AG FTL RHD GEN ALYS MPCR (UNITY Fetal RhD™ NIPT)	Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.
	0648U	ONC SOL TUM TGSA 42/10/18GEN (Oncomine Dx Express Test)
	0650U	RX METAB ADVRS RXNS&RSPSE 9 (CKM PGx™ Panel (Hypertension and Cardiovascular-kidney-metabolic pharmacogenetic panel))
	0651U	ONC HERED CA 55GEN NGS DMLPA ( OncoDx™ (Hereditary Germline Cancer Genetics Panel))
	0652U	RX METAB ADVERSE DNA ALYS 13 (RenaPGx™ (Renal Pharmacogenetic Test))
	0657U	RARE DS SEQ ALYS CMPRTR NUC (GenomeDx Rapid, Comparator)
	0658U	RARE DS NUC&MITOCHDRL DNA (GenomeDx Rapid, Proband)
	0659U	RARE DS ULTRAPID WGSALYS DNA (GenomeDx ultraRapid, Proband)

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.