Effective April 1, 2022, we are adding new codes to the prior authorization list for cardiovascular procedures, prostate procedures, spine surgery and cosmetic surgery. These changes impact UnitedHealthcare Community Plans (Medicaid, CHIP, long-term care and Medicare-Medicaid Plans (MMP)) in certain states.
See below to view the list of procedure codes requiring prior authorization with notation of applicable states.
Adding prior authorization medical necessity effective April 1, 2022, for listed states.
CPT® code | Description | States impacted |
---|---|---|
37243 |
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia or infarction |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Kentucky, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia, Washington Texas MMP, Ohio MMP, Kentucky, Minnesota North Carolina: Existing requirement, recategorization only from Vein Procedures |
52441 |
Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Maryland, Michigan, Missouri, Mississippi, Nebraska, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Virginia, Wisconsin |
52442 |
Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Maryland, Michigan, Missouri, Mississippi, Nebraska, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Virginia, Wisconsin |
53850 |
Transurethral destruction of prostate tissue; by microwave thermotherapy |
Arizona, California, Hawaii, Kansas, Massachusetts Senior Care Options, Massachusetts One, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Washington, Wisconsin |
53852 |
Transurethral destruction of prostate tissue; by radiofrequency thermotherapy |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas MMP, Virginia, Washington, Wisconsin |
55866 |
Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed |
Rhode Island Existing requirement all other states; recategorization only from Experimental Procedures |
55873 |
Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) |
Arizona, Florida (excludes LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas MMP, Virginia, Washington, Wisconsin |
55874 |
Transperineal placement of biodegradable material, periprostatic, single or multiple injection(s), including image guidance, when performed |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Virginia |
Adding prior authorization medical necessity effective April 1, 2022, for listed states.
CPT® code | Description | States impacted |
---|---|---|
22510 |
PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC |
Arizona, California, Florida (excluding LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Washington, Wisconsin |
22511 |
PERQ VERTEBROPLASTY UNI/BI INJECTION LUMBOSACRAL |
Arizona, California, Florida (excluding LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Wisconsin |
22512 |
VERTEBROPLASTY EACH ADDL CERVICOTHOR/LUMBOSACRAL |
Arizona, California, Florida (excluding LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Wisconsin |
22513 |
PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION |
Arizona, California, Florida (excluding LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Washington, Wisconsin |
22514 |
PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR |
Arizona LTSS California, Florida (excludes LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Nebraska, Ohio MMP, Tennessee, Texas MMP, Virginia, Wisconsin Recategorization only from Site of Service; site requirement continues to apply for Arizona, Missouri, Mississippi, Nebraska, New York, Ohio, Pennsylvania, Rhode Island, Texas, Washington |
22515 |
PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Wisconsin |
Adding prior authorization medical necessity effective April 1, 2022, for listed states. Applies to enrollees ages 18 and older.
CPT® code | Description | States impacted |
---|---|---|
93580 |
Percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant |
Arizona, California, Florida (excludes LTSS), Hawaii, Kansas, Kentucky, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, New York, Ohio, Ohio MMP, Pennsylvania, Rhode Island, Tennessee, Texas, Texas MMP, Virginia, Wisconsin |
Adding prior authorization medical necessity effective April 1, 2022, for listed states.
CPT® code | Description | States impacted |
---|---|---|
15877 |
Suction assisted lipectomy; trunk |
Michigan |
15878 |
Suction assisted lipectomy; upper extremity |
Hawaii, Kansas, Michigan, New York, Rhode Island, Tennessee, Washington
Existing requirement; recategorization only from Gender Dysphoria Treatment applies to Pennsylvania |
15879 |
Suction assisted lipectomy; lower extremity |
Hawaii, Kansas, Michigan, New York, Rhode Island, Tennessee
Existing requirement; recategorization only from Gender Dysphoria Treatment applies to Pennsylvania |
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