Effective November 15, 2023: Removal of Prior Authorization Requirement for Certain Medical Supplies and Equipment

Date: 11/10/23

Superior HealthPlan will no longer require prior authorization for certain procedures for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP effective November 15, 2023. Below are the Healthcare Common Procedure Coding System (HCPCS) codes that are included in this change to the prior authorization requirements.

HCPCS Codes	Description
A0426	AMB SRV AD LIFE SUP NON-ER TRANS L1
A4301	IMPL ACSS TOTAL CATH PORT/RESRVOR
A4321	THERAP AGENT FOR URINARY CATHETER IRRIGATION
A4510	SURGICAL STOCKINGS FULL LENGTH EACH
A4575	TOPICAL HYPERBARIC O2 CHAMBER, DISPOSABLE
A4648	LOW OSMOLAR CONTRAST MATERIAL
A4650	CENTRIFUGE (W/CALIBRATED TUBES & SEALEASE)
A4651	CALIBRATED MICROCAPILLARY TUBE EA
A4652	MICROCAPPILARY TUBE SEALANT
A4690	DIALYZERS (ARTFCL KIDNEY) ALL BRAND/SZS PER UNIT
A4706	BICARBONATE CONCENTRATE, SOLU FOR HEMODIALYSIS PER GALLON
A4707	BICARBONATE CONCENTRATE, POWDER, FOR HEMODIALYSIS, PAKET
A4708	ACETATE CONCENTRATE SOLUTION, HEMODIALYSIS PER GALLON
A4709	ACID CONCENTRATE, SOLUTION, HEMODIALYSIS, PER GALLON
A4714	TREATED WATER USED IN DIALYSIS UNIT
A4719	Y SET TUBING FOR PERITONIAL DIALYSIS
A4720	DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID
A4721	DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID
A4722	DIALYSATE SOLUTION ANY CONCENTRATION OF DEXTROSE, FLUID
A4723	DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID
A4724	DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID
A4725	DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID
A4726	DIALYSATE SOLUTION, ANY CONCENTRATION OF DEXTROSE, FLUID
A4730	FISTULA CANNULATION SET DIALYSIS ONLY
A4736	TOPICAL ANESTHETIC, FOR DIALYSIS, PER GRAM
A4737	INJECTABLE ANESTHETIC, FOR DIALYSIS, PER 10 ML
A4740	SHUNT ACCESSORIES DIALYSIS ONLY
A4750	BLOOD TUBING ARTERIAL/VENOUS EACH
A4755	BLOOD TUBING ARTERIAL & VENOUS COMBINED
A4760	DIALYSATE STANDARD TESTING SOLUTION SUPPLIES
A4765	DIALYSATE CONCENTRATE ADDITIVES EACH
A4766	DIALYSATE CONCENTRATE, SOLUTION ADDITIVE FOR PERIT DIALYSIS
A4774	AMMONIA TEST PAPER PER BOX
A4802	PROTAMINE SULFATE, FOR HEMODIALYSIS, PER 50 MG
A4913	MISC DIALYSIS SUPPLIES NOT IDENTIFIED BY REPORT
A4918	VENOUS PRESSURE CLAMPS EACH
A4928	SURGICAL MASK PER 20
A4929	TOURNIQUET FOR DIALYSIS, EACH
A5105	URINARY SUSPENSORY
A5500	DIABETIC ONLY-FIT/PREP/SUPP SHOE FOR INSERT/SHOE
A5501	DIABETIC ONLY-FIT/PREP/SUPP CUST MOLD SHOE/SHOE
A5503	DIABETIC ONLY-MOD/FIT SHOE W/ROLL/ROCK BTM/SHOE
A5504	DIABETIC ONLY-MODIFY/FIT SHOE W/WEDGE(S)/SHOE
A5505	DIABETIC ONLY-MOD/FIT SHOE W/METATARSAL BAR/SHOE
A5506	DIABETIC ONLY-MOD/FIT SHOE W/OFF-SET HEEL/SHOE
A5507	DIABETIC ONLY-NOS MODIFY/FIT SHOE-PER SHOE
A6222	GAUZE <=16 IN NO W/SAL W/O B
A6228	GAUZE <= 16 SQ IN WATER/SAL
A6230	GAUZE > 48 SQ IN WATER/SALNE
A8003	HELMET PROTECTIVE HARD CUSTOM FABR INCL ALL COMPONENTS/ACCESSOR
A9152	SINGLE VIT/MINERAL/TRACE ELEMENT ORAL-DOSE NOS
A9153	MX VIT W/WO MINERLS&TRACE ELEMS ORL PER DOSE NOS
A9273	COLD/HOT FL BTL ICE CAP/C HEAT AND/ COLD WRAP ANY
A9507	RP DX INDIUM IN 111 CAPROMABPENDETIDE /DOSE
A9542	INDIUM IN-111 IBRITUMOMAB TIUXETAN DIAGNOSTIC /STUDY DOSE UP TO 5
A9543	YTTRIUM Y-90 IBRITUMOMAB TIUXETAN THERAPEUTIC TREATMENT DOSE UP TO 40
A9600	SUPP THERAP RADIOPHRM STRONTIUM-89 CL PER MCI
B4083	STOMACH TUBE LEVINE TYPE
B4164	PARENTERAL NUTRITION CARBO 50% /LESS HOMEMIX
B4168	PARENTERAL NUTRITION AMINO ACID 3.5% HOMEMIX
B4172	PARENTERAL NUTRITION AMINO ACID 5.5-7% HOMEMIX
B4176	PARENTERAL NUTRITION AMINO ACID 7-8.5% HOMEMIX
B4178	PARENTERAL NUTRITION AMINO ACID 8.5% MIN HOMEMIX
B4180	PARENTERAL NUTRITION CARBO MORE 50% HOMEMIX
B4189	PARENTERAL NUTRITION COMPOUND 10-51 GMS PROTEIN
B4193	PARENTERAL NUTRITION COMPOUND 52-73 GMS PROTEIN
B4197	PARENTERAL NUTRITION COMPOUND 74-100 GMS PROTEIN
B4199	PARENTERAL NUTRITION COMPOUND OVER 100 GM PROT
B4216	PARENTERAL NUTRITION ADDITIVES HOMEMIX PER DAY
B4222	PARENTERAL NUTRITION SUPPLY KIT HOME MIX PER DAY
B5000	PARENTERAL SOL RENAL-AMIROSY
B5100	PARENTERAL SOLUTION HEPATIC
B5200	PARENTERAL SOL HEPATIC FREAM
C9359	IMPLNT, BON VOID FILLER-PUTTY
C9360	SURGIMEND, NEONATAL
C9361	NEUROMEND NERVE WRAP
C9362	IMPLNT,BON VOID FILLER-STRIP
C9402	SPL RADOPHRM TX I-131 SODIM IODIDE CAP MCI BRAND
E0202	PHOTOTHERAPY (BILIRUBIN) LIGHT W/PHOTOMETER
E0431	PORTABLE GAS O2 SYSTEM RENTAL; INCL EQUIP
E1011	MOD PED WHLCHAIR WIDTH ADJ PKG
E1510	KIDNEY DIALYSATE DELIVERY SYSTEM (COMPLETE)
E1560	BLOOD LEAK DETECTOR FOR DIALYSIS
E1580	UNIPUNCTURE CONTROL SYSTEM FOR DIALYSIS
E1590	HEMODIALYSIS MACHINE
E1592	AUTOMATIC INTERMITTENT PERITONEAL DIALYSIS SYS
E1594	CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS
E1620	BLOOD PUMP FOR DIALYSIS
E1630	RECIPROCATING PERITONEAL DIALYSIS SYSTEM
E1632	WEARABLE ARTIFICIAL KIDNEY
E1635	COMPACT (PORTABLE) TRAVEL HEMODIALYZER SYSTEM
E1699	DIALYSIS EQUIPMENT UNSPECIFIED BY REPORT
E1806	SPS WRIST DEVICE
E2228	MWC ACC WHEELCHAIR BRAKE
E2291	BACK PLANAR PED SZ WC INCL FIX ATTCHING HARDWARE
E2292	SEAT PLANAR PED SZ WC INCL FIX ATTCHING HARDWARE
E2293	BACK CONTOURED PED WC INCL FIX ATTCH HARDWARE
E2294	SEAT CONTOURED PED WC INCL FIX ATTCH HARDWARE
K0730	CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM
Q0506	LITH-ION BATT ELEC/PNEUM VAD
Q3031	COLLAGEN SKIN TEST
S0515	SCLERAL LENS LIQUID BANDAGE DEVICE PER LENS
S8415	SUPPLIES FOR HOME DELIVERY OF INFANT
V2627	SCLERAL COVER SHELL
V2631	IRIS SUPPORTED INTRAOCULAR LENS
V2790	AMNIOTIC MEMBRN SURG RECON P/PROC
V5014	REPAIR/MODIFICATION OF A HEARING AID
V5336	REPAIR MODIFY AUGMENT COMMUNICATION SYS/DEVICE

To review prior authorization requirements, please visit Superior’s Authorization Requirements webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.