Effective July 1, 2025: Changes to Prior Authorization Requirements for Cardiology Services and Procedures
Date: 04/01/25
Effective July 1, 2025, Evolent Specialty Services, Inc., Texas URA #1777359, will be performing utilization review for cardiac services and procedures that require prior authorization. As a reminder, prior authorization is required for certain cardiac services and procedures for Superior HealthPlan Medicaid members aged 21 and over (STAR, STAR Health, STAR+PLUS) STAR+PLUS Medicare-Medicaid Plan (MMP) and Ambetter from Superior HealthPlan members aged 18 and older.
- For additional information on the transition of cardiac procedures to Evolent view Superior’s Cardiology Procedures: Transition of Utilization Review from TurningPoint to Evolent Effective for Service Dates beginning July 1, 2025 web post.
- Prior authorization requests can be submitted to Evolent's website by calling 1-800-642-7554, or fax to 1-800-784-6864. To view Evolent’s cardiac clinical guidelines visit Evolent’s Cardiology webpage.
Additionally, there will be added cardiac services and procedures that require prior authorization effective July 1, 2025. These are listed by procedure code in the tables below.
Medicaid, STAR+PLUS MMP and Ambetter Required Prior Authorization for Adults:
| CPT Code | CPT Description | Criteria |
|---|---|---|
75625 | Aortography, abdominal, by serialography, radiological supervision and interpretation |
Evolent’s cardiac clinical guidelines that will be utilized for these services can be found on Evolent’s Cardiology webpage.
|
75630 | Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation | |
75726 | Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation | |
93456 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization | |
93457 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization | |
93460 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | |
93461 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | |
93458 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | |
93459 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | |
92920 | Percutaneous Transluminal Coronary Angioplasty; single Major Coronary Artery or Branch | |
92921 | Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) | |
92924 | Percutaneous Transluminal Coronary atherectomy, with Coronary Angioplasty when Performed; single Major Coronary Artery or Branch | |
93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; | |
93455 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography | |
93653 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry | |
93654 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed | |
93656 | Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography including imaging supervision and interpretation, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, right ventricular pacing/recording, and His bundle recording, when performed | |
36245 | Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family | |
36246 | Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family | |
36247 | Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family | |
92973 | Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code for primary procedure) | |
75710 | Angiography, extremity, unilateral, radiological supervision and interpretation | |
75716 | Angiography, extremity, bilateral, radiological supervision and interpretation | |
92978 | Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure) | |
93620 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording |
Ambetter Only Required Prior Authorization for Adults:
CPT Code | CPT Description | Criteria |
33289 | Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed | Evolent’s cardiac clinical guidelines that will be utilized for these services can be found on Evolent’s Cardiology webpage. |
For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.