Effective October 1, 2024: Prior Authorization Update for New CPT Codes
Date: 06/28/24
Effective October 1, 2024, Ambetter from Superior HealthPlan will require prior authorization for the following new American Medical Association Current Procedural Terminology (CPT) Proprietary Laboratory Analyses (PLA) codes and CPT Category III codes.
Ambetter ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. The codes impacted by this change are:
CPT Code | Description |
|---|---|
0020M | ONC CNS ALYS 30000 DNA METHYLATION LOCI TUM TISS |
0450U | ONC MM LC-MS/MS MONOCLONAL P-PRTN SEQ ALYS SERUM |
0451U | ONC MM LC-MS/MS PEPTIDE ION QUANTIFICATION SERUM |
0452U | ONC BLADDER MTHYL PENK DNA DETCJ LTE-QMSP URINE |
0453U | ONC CLRCT CA CFDNA MTHYLTN BSD QUAN PCR ASY PLSM |
0454U | RARE DS ID VRTJ INVRJ INSJ TLCJ OPT GENOME MAPG |
0456U | AI RA NGS GEN XPRSN 19 GEN WHL BLD ALYS ANTI-CCP |
0457U | PFAS 9 PFAS COMPOUNDS LC-MS/MS PLASMA/SERUM QUAN |
0458U | ONC BREAST CA S100 A8&A9 ELISA TEAR FLUID ALG |
0459U | ABETA42 & TTAU ECLIA CEREBRAL SPINAL FLUID RATIO |
0460U | ONC WHL BLD/BUCCAL DNA SNP GNOTYP RT-PCR 24 GENE |
0461U | ONC RX-GENOMIC ALYS SNP GNOTYP RT-PCR 24 GENES |
0462U | MELATONIN LVL TEST SLEEP STUDY 7/9 SAMPLE ELISA |
0463U | ONC CERVIX MRNA GENXPRSN 14 BMRK E6&E7 HPV NASBA |
0465U | ONC UROTHELIAL CARC DNA QMSP 2 GENES ALG ALYS |
0466U | CRD CAD DNA GWAS 564856 SNP TRGT VARIANT GNOTYP |
0467U | ONC BLDR DNA NGS 60 GEN&WHL GENOME ANEUP UR ALG |
0468U | HEP NASH MIR-34A-5P A2M YKL40 HBA1C SRM&WHL BLD |
0469U | RARE DS WHL GENOM SEQ ALYS CHRMOML ABNR FTL SAMP |
0470U | ONC OROP DETCJ MRD NGS QUAN EVAL 8DNA CFHPV16&18 |
0472U | CA VI PSP&SP1 ANTB ELISA SEMIQL BLD SJOGREN SYND |
0473U | ONC SOLID TUMOR NGS DNA FFPE TISS BLD/SLV 648GEN |
0474U | HERED PAN CA GSAP 88 GENES 20DUP/DEL NGS BLD/SLV |
0475U | HERED PRST8 CA-RLTD DO GSAP NGS CGH EVAL 23 GENE |
0867T | TPLA B9 PROSTATIC HYPERPLASIA PRST8 VOL>=50 ML |
0868T | HIGH-RESOLUTION GASTRIC ELECTROPHYSIOLOGY MAPG |
0869T | NJX B1 SUB MATRL B1&/SFT TISSUE HW FIXJ AGMNTJ |
0870T | IMPLANTATION SUBQ PERITONEAL ASCITES PUMP SYS |
0871T | REPLACEMENT SUBCUTANEOUS PERITONEAL ASCITES PUMP |
0872T | RPLCMT INDWELLING BLADDER & PERITONEAL CATHETERS |
0873T | REVJ SUBQ IMPL PERITONEAL ASCITES PUMP SYSTEM |
0874T | REMOVAL PERITONEAL ASCITES PUMP SYSTEM |
0876T | DUPLEX SCAN HEMODIALYSIS FISTULA CPTR AIDED LMTD |
0877T | AUGMNT ALYS CH CT IMG DATA ILD WO CNCRNT CT EXAM |
0878T | AUGMNT ALYS CH CT IMG DATA ILD W/CNCRNT CT EXAM |
0879T | AUGMNT ALYS CH CT IMG DATA ILD DATA PREP&TRNSMS |
0880T | AUGMNT ALYS CH CT IMG DATA ILD PHYS/QHP I&R |
0881T | CRTX ORAL CAVITY TEMP REGULATED FLU COOLING SYS |
0884T | ESPHGSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH |
0885T | COLSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH |
0886T | SGMDSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH |
0888T | HISTOTRIPSY MALIGNANT RENAL TISSUE W/IMG GDN |
0889T | PERSONALIZED TARGET DEVELOPMENT ARHFCMRIGTBS |
0890T | ARHFCMRIGTBS 1ST MOTOR THRESHOLD DETER 1ST TX D |
0891T | ARHFCMRIGTBS SUBSEQUENT TREATMENT DAY |
0892T | ARHFCMRIGTBS SBSQ MOTOR THRESHLD REDETER PR TX D |
0893T | N-INVAS ASSMT BLD OXY GAS XCHNG EFF&CARDRESP I&R |
0897T | N-INVAS AUGMNT ARRHYT ALYS QUAN CAR ARRHYT SIMUL |
0898T | NONINVASIVE PROSTATE CANCER ESTIMATION MAP |
0899T | N-INVAS DETER AQMBF AUGMNT ALG ALYS DATASET CMR |
0900T | N-INVAS EST AQMBF ASSITIVE ALG ALYS DATASET CMR |
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.