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Effective January 1, 2024: Prior Authorization Requirements for Certain CPT Codes

Date: 09/29/23

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

Please note:

  • Prior authorization requests for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members 20 years of age and younger should be submitted to Superior.
  • Prior authorization requests for Ambetter members of all ages and Medicaid members 21 years of age and older should be submitted to National Imaging Associates, Inc. (NIA).

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 January 1, 2024.

CPT Code

CPT Description

Criteria

64510

INJECTION ANESTHETIC AGENT; STELLATE GANGLION

Medicaid and CHIP members 20 years of age and younger: refer to CP.MP.170 Nerve Blocks for Pain Management SuperiorHealthPlan.com/Policies

For Ambetter members of all ages, Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members 21 years of age and older: review NIA clinical guidelines at https://www1.radmd.com/solutions/interventional-pain-management-solution.aspx or by calling 1-800-642-7554

 

64517

INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS

64520

INJECTION ANESTHETIC AGENT; LUMBAR/THORACIC

77003

FLUOROGUIDE FOR SPINE INJECTION

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

To review NIA prior authorization requirements, please visit RadMD.com.

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