Effective February 15, 2023: Removal of Prior Authorization Requirement for Certain Musculoskeletal, Respiratory, Integumentary, Hematic and Digestive Procedures
Date: 02/09/23
Effective February 15, 2023, Superior HealthPlan will no longer require prior authorization for certain procedures for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP, below are the Current Procedural Terminology (CPT) codes included in this change to the prior authorization requirements.
CPT Codes | Description |
|---|---|
Hematic and Digestive System |
|
38243 | TRANSPLJ HEMATOPOIETIC BOOST |
41800 | DRAINAGE ABSCESS/CYST FROM DENTOALVEOLAR STRUCT |
41805 | REMOV EMBED FB-DENTOALVEOLAR STRUCT; SOFT TISS |
41826 | EXC LES/TUMOR DENTOALVEOLAR STRUCT; W/SIMPL REPR |
41827 | EXC LES DENTOALVEOLAR STRUCT; W/COMPLX REPR |
42260 | REPR NASOLABIAL FISTULA |
43653 | LAPAROSCOPY GASTROSTOMY W/O CONSTRUCTION OF GASTRIC TUBE |
43772 | LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE |
43774 | LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT |
43887 | GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY |
46070 | INCS ANAL SEPTUM (INFANT) |
Musculoskeletal |
|
28010 | TENOT PERCUT TOE; SINGL TENDON |
28011 | TENOT PERCUT TOE; MX TENDON |
Respiratory |
|
30620 | SEPTAL/OTHER INTRANASAL DERMATOPLASTY |
31505 | LARYNGOSCOPY INDIRECT (SEPART PROC); DX |
Integumentary |
|
11600 | EXC MAL LES TRNK ARMS/LEGS; 0.5/< |
11601 | EXC MAL LES TRNK ARMS/LEGS; 0.6-1.0 |
11602 | EXC MAL LES TRNK ARMS/LEGS; 1.1-2.0 |
11603 | EXC TR-EXT MAL+MARG 2.1-3 CM |
11604 | EXC MAL LES TRNK ARMS/LEGS; 3.1-4.0 |
11620 | EXC MAL LES SCLP HND FT GNT; 0.5/< |
11621 | EXC MAL LES SCLP HND FT GNT;0.6-1.0 |
11622 | EXC MAL LES SCLP HND FT GNT;1.1-2.0 |
11623 | EXC S/N/H/F/G MAL+MRG 2.1-3 |
11624 | EXC MAL LES SCLP HND FT GNT;3.1-4.0 |
11640 | EXC MAL LES FCE ERS EYELD NSE;0.5/< |
11641 | EXC MAL LES FCE ERS EYELD; 0.6-1.0 |
11642 | EXC MAL LES FCE ERS EYELD; 1.1-2.0 |
11643 | EXC MAL LES FCE ERS EYELD; 2.1-3.0 |
11644 | EXC MAL LES FCE ERS EYELD; 3.1-4.0 |
12034 | INTMD WND REPAIR S/TR/EXT |
12035 | INTMD WND REPAIR S/TR/EXT |
12036 | INTMD WND REPAIR S/TR/EXT |
12037 | INTMD WND REPAIR S/TR/EXT |
12041 | INTMD WND REPAIR N-HF/GENIT |
12042 | INTMD WND REPAIR N-HG/GENIT |
12044 | INTMD WND REPAIR N-HG/GENIT |
12045 | INTMD WND REPAIR N-HG/GENIT |
12046 | INTMD WND REPAIR N-HG/GENIT |
12047 | INTMD WND REPAIR N-HG/GENIT |
12051 | INTMD WND REPAIR FACE/MM |
12054 | INTMD WND REPAIR FACE/MM |
12055 | INTMD WND REPAIR FACE/MM |
12057 | INTMD WND REPAIR FACE/MM |
14000 | ADJACENT TISS TRANSF TRUNK; DEFECT 10 SQ CM/LESS |
14401 | ADJACENT TISS TRANSF TRUNK; 10.1 TO 30.0 SQ CM |
14021 | ADJACENT TRANSF SCLP/ARMS/LEGS; 10.1-30.00 SQ CM |
14040 | ADJACENT TRANSF CHIN/NECK/AX/FT; 10 SQ CM/LESS |
14041 | ADJACENT TRANSF CHIN/NECK/AX/FT; 10.1-30.0 SQ CM |
14061 | ADJACENT TRANSF LIDS/NOSE/LIPS; 10.1-30.0 SQ CM |
14300 | ADJACENT TRANSF MORE THAN 30.0 SQ CM COMPLIC |
15840 | GFT FACIAL NERV PARALYSIS; FREE FASCIA GFT |
15841 | GFT FACIAL NERV PARALYSIS; FREE MUSCL GFT |
15842 | FLAP FOR FACE NERVE PALSY |
15845 | GFT FACIAL NERV PARALYSIS; REGIONAL MUSCL TRANSF |
19330 | RMVL RUPTURED BREAST IMPLANT W/IMPLANT CONTENTS |
To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.
For questions or additional information, contact Superior HealthPlan Prior Authorization department at 1-800-218-7508.