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Effective August 1, 2024: Prior Authorization for Certain Genetic Procedure Codes

Date: 04/18/24

Superior HealthPlan will require prior authorization for certain genetic testing Current Procedural Terminology (CPT) codes for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter from Superior HealthPlan members.

Prior authorization requests for members of all ages should be submitted to, Evolent Specialty Services, Inc. (Evolent) at www.RadMD.com, by calling 1-800-642-7554 or fax to 1-800-784-6864.

Superior 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 August 1, 2024.

CPT Code

CPT Description

Criteria

81457

SO NEO GSAP DNA ALYS MICROSATELLITE INSTABILITY

Evolent’s genetic testing clinical guidelines that will be utilized for these services can be found on Evolent’s Genetic Testing Policies webpage.

 

81456

SO NEO GSAP DNA ALY CPY NMBR AND MICROSATELLITE INS

81459

SO NEO GSAP DNA ALYS/DNA AND RNA CPY NMBR MCRSTL INS

81462

SO NEO GSAP CLL FR DNA/DNA AND RNA CPY NMBR AND REARGMT

81463

SO NEO GSAP CLL FR DNA ALYS CPY NMBR AND MCRSTL INS

81464

SO NEO GSAP CL FR DNA/DNA AND RNA CPY NMBR MCRST INS

To review Evolent’s prior authorization requirements, please visit www1.radmd.com.

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