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Effective October 1, 2024: Prior Authorization Update for New CPT Codes

Date: 07/01/24

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.