Effective May 1, 2022: Oncology Breast MRNA

Date: 01/26/22

Superior HealthPlan will require prior authorization for CPT code 81519, Oncology Breast MRNA, for Medicaid, CHIP and Superior HealthPlan Medicare-Medicaid Plan (MMP) members. Superior HealthPlan will utilize Change Healthcare’s InterQual as the medical necessity review criteria. Superior HealthPlan 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 May 1, 2022

Prior Authorization	Applicable Products	Criteria
Oncology Breast MRNA CPT code 81519	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, MMP	Change Healthcare’s InterQual criteria, proprietary, but available upon request for CPT code 81519

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.