January 01, 2022

Medicaid: New prior authorization codes in select states

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.

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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, peri-prostatic, 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

PCA-1-21-04516-Clinical-News_12082021