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Ambetter from Louisiana Healthcare Connections prior authorization updates effective 7/1/2024 for new American Medical Association Current Procedural Terminology (CPT®) codes.

Date: 05/20/24

The following new CPT Proprietary Laboratory Analyses (PLA) codes and CPT Category III codes will require prior auth, unless determined to be a non-covered service, upon their effective date of 7/1/2024. For other established codes, please use the Pre-Auth Check Tools on our websites to confirm if the code(s) requires prior authorization. Prior authorization requirements vary based on the line of business, so please select the applicable Pre-Auth Check Tool by the line of business. 

CODE
DESCRIPTION
0020MONC CNS ALYS 30000 DNA
METHYLATION LOCI TUM TISS
0450UONC MM LC-MS/MS
MONOCLONAL P-PRTN SEQ ALYS SERUM
0451UONC MM LC-MS/MS PEPTIDE ION
QUANTIFICATION SERUM
0452UONC BLADDER MTHYL PENK DNA
DETCJ LTE-QMSP URINE
0453UONC CLRCT CA CFDNA
MTHYLTN BSD QUAN PCR ASY PLSM
0454URARE DS ID VRTJ INVRJ
INSJ TLCJ OPT GENOME MAPG
0456UAI RA NGS GEN XPRSN 19 GEN WHL BLD ALYS
ANTI-CCP
0457UPFAS 9 PFAS COMPOUNDS LC-MS/MS PLASMA/SERUM QUAN
0458UONC BREAST CA S100 A8&A9 ELISA TEAR FLUID
ALG
0459UABETA42 & TTAU ECLIA CEREBRAL SPINAL FLUID
RATIO
0460UONC WHL BLD/BUCCAL DNA SNP GNOTYP RT-PCR 24 GENE
0461UONC RX-GENOMIC ALYS SNP GNOTYP RT-PCR 24 GENES
0462UMELATONIN LVL TEST SLEEP STUDY 7/9 SAMPLE ELISA
0463UONC CERVIX MRNA GENXPRSN 14 BMRK E6&E7 HPV
NASBA
0465UONC UROTHELIAL CARC DNA QMSP 2 GENES ALG ALYS
0466UCRD CAD DNA GWAS 564856 SNP TRGT VARIANT GNOTYP
0467UONC BLDR DNA NGS 60 GEN&WHL GENOME ANEUP UR
ALG
0468UHEP NASH MIR-34A-5P A2M YKL40 HBA1C SRM&WHL
BLD
0469URARE DS WHL GENOM SEQ ALYS CHRMOML ABNR FTL SAMP
0470UONC OROP DETCJ MRD NGS QUAN EVAL 8DNA
CFHPV16&18
0472UCA VI PSP&SP1 ANTB ELISA SEMIQL BLD SJOGREN
SYND
0473UONC SOLID TUMOR NGS DNA FFPE TISS BLD/SLV 648GEN
0474UHERED PAN CA GSAP 88 GENES 20DUP/DEL NGS BLD/SLV
0475UHERED PRST8 CA-RLTD DO GSAP NGS CGH EVAL 23 GENE
0867T

TPLA B9 PROSTATIC HYPERPLASIA PRST8
VOL>=50 ML
0868THIGH-RESOLUTION GASTRIC ELECTROPHYSIOLOGY MAPG
0869TNJX B1 SUB MATRL B1&/SFT TISSUE HW FIXJ
AGMNTJ
0870TIMPLANTATION SUBQ PERITONEAL ASCITES PUMP SYS
0871TREPLACEMENT SUBCUTANEOUS PERITONEAL ASCITES PUMP
0872TRPLCMT INDWELLING BLADDER & PERITONEAL
CATHETERS
0873TREVJ SUBQ IMPL PERITONEAL ASCITES PUMP SYSTEM
0874TREMOVAL PERITONEAL ASCITES PUMP SYSTEM
0876TDUPLEX SCAN HEMODIALYSIS FISTULA
CPTR AIDED LMTD
0877TAUGMNT ALYS CH CT IMG DATA ILD WO CNCRNT CT EXAM
0878TAUGMNT ALYS CH CT IMG DATA ILD W/CNCRNT CT EXAM
0879TAUGMNT ALYS CH CT IMG DATA ILD DATA
PREP&TRNSMS
0880TAUGMNT ALYS CH CT IMG DATA ILD PHYS/QHP I&R
0881TCRTX ORAL CAVITY TEMP REGULATED FLU COOLING SYS
0884TESPHGSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH
0885TCOLSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH
0886TSGMDSC FLX TRNSORL 1ST TNDSC DILAT RX BALO CATH
0888THISTOTRIPSY MALIGNANT RENAL TISSUE W/IMG GDN
0889TPERSONALIZED TARGET DEVELOPMENT ARHFCMRIGTBS
0890TARHFCMRIGTBS 1ST MOTOR THRESHOLD DETER 1ST TX D
0891TARHFCMRIGTBS SUBSEQUENT TREATMENT DAY
0892TARHFCMRIGTBS SBSQ MOTOR THRESHLD REDETER PR TX D
0893TN-INVAS ASSMT BLD OXY GAS XCHNG EFF&CARDRESP
I&R
0897TN-INVAS AUGMNT ARRHYT ALYS QUAN CAR ARRHYT SIMUL
0898TNONINVASIVE PROSTATE CANCER ESTIMATION MAP
0899TN-INVAS DETER AQMBF AUGMNT ALG ALYS DATASET CMR
0900TN-INVAS EST AQMBF ASSITIVE ALG ALYS DATASET CMR