PRIOR AUTHORIZATION GUIDELINESj0190 injection, biperiden lactate, per 5 mg j0215 injection,...
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PRIOR AUTHORIZATION GUIDELINES Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION Effective 12/1/2019 These guidelines are available at www.care1staz.com PH 602.778.1800 (provider menu = option 5) FAX 602.778.1838 Medical/Dental Covered Services Special Comments Prior Authorization Requirement Care1st AHCCCS & DDD Allergy Immunotherapy *Allergy immunotherapy including desensitization treatments administered via subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT) or via other routes of administration, is not covered for persons age 21 years and older. No authorization required for members under the age of 21 *Yes Allergy Testing Yes Anesthesia (in office) Mobile Anesthesia services provided in an office Yes ASC Procedures *Attachment II lists ASC procedures that require prior auth *Yes Chiropractic Services Yes Cosmetic & Plastic Surgery Includes Consults, Follow-up Visits; all Procedures & Medical Services Yes Dental Services Please refer to Advantica/Care1st Clinical and Billing Guidelines for Members under 21 and Advantica/Care1st Clinical and Billing Guidelines for Members 21 and Over Dental Trauma Please refer to Advantica/Care1st Clinical and Billing Guidelines for Members under 21 and Advantica/Care1st Clinical and Billing Guidelines for Members 21 and Over Diabetic Education/ All Nutritional Services Yes Diagnostic Testing EMG, EP testing, heart caths, nerve conduction studies, nuclear cardiac stress test, TEE, tilt table Yes Dialysis Notification required for the Initial start only *Prior auth also required when Care1st is 2ndary *Yes DME (Orthotics & Prosthetics see pg 2) Obtain items by contacting Plan’s preferred DME provider *Prior auth required for CRS members and when Care1st is 2ndary unless Medicare is primary *None EEG None Endoscopy (i.e. colonoscopies, colposcopies, EGDs, etc.) if performed by PAR provider @ PAR facility None Enteral/Tube Feed Obtain services by contacting Plan’s preferred Enteral provider *Prior auth always required unless Medicare is primary *Yes Experimental Procedures Including clinical trial services Not Covered Family Planning Includes services performed in office; Attachment I lists injectables that require prior auth Self Referral Genetic Testing See Specialist category Yes Hearing Aids *Hearing aids are covered for AHCCCS members under age 21. *Yes Home Health Obtain services by contacting Plan’s preferred Home Health provider *Prior auth also required when Care1st is 2ndary unless Medicare is primary *None
Transcript of PRIOR AUTHORIZATION GUIDELINESj0190 injection, biperiden lactate, per 5 mg j0215 injection,...
PRIOR AUTHORIZATION GUIDELINES
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 12/1/2019 These guidelines are available at www.care1staz.com
PH 602.778.1800 (provider menu = option 5) FAX 602.778.1838
Medical/Dental Covered Services
Special Comments
Prior Authorization Requirement
Care1st AHCCCS & DDD
Allergy Immunotherapy
*Allergy immunotherapy including desensitization treatments administered via subcutaneous injections (allergy shots), sublingual immunotherapy (SLIT) or via other routes of administration, is not covered for persons age 21 years and older.
No authorization required for members under the age of 21
*Yes
Allergy Testing Yes
Anesthesia (in office) Mobile Anesthesia services provided in an office Yes
ASC Procedures *Attachment II lists ASC procedures that require prior auth *Yes
Chiropractic Services Yes
Cosmetic & Plastic Surgery
Includes Consults, Follow-up Visits; all Procedures & Medical Services Yes
Dental Services
Please refer to Advantica/Care1st Clinical and Billing Guidelines for
Members under 21 and Advantica/Care1st Clinical and Billing Guidelines for Members 21 and Over
Dental Trauma
Please refer to Advantica/Care1st Clinical and Billing Guidelines for
Members under 21 and Advantica/Care1st Clinical and Billing Guidelines for Members 21 and Over
Diabetic Education/ All Nutritional Services
Yes
Diagnostic Testing EMG, EP testing, heart caths, nerve conduction studies, nuclear cardiac stress test, TEE, tilt table
Yes
Dialysis Notification required for the Initial start only
*Prior auth also required when Care1st is 2ndary *Yes
DME (Orthotics & Prosthetics see pg 2)
Obtain items by contacting Plan’s preferred DME provider
*Prior auth required for CRS members and when Care1st is 2ndary unless Medicare is primary
*None
EEG None
Endoscopy (i.e. colonoscopies, colposcopies, EGDs, etc.) if performed by PAR provider @ PAR facility
None
Enteral/Tube Feed Obtain services by contacting Plan’s preferred Enteral provider
*Prior auth always required unless Medicare is primary *Yes
Experimental Procedures
Including clinical trial services Not Covered
Family Planning Includes services performed in office; Attachment I lists injectables that require prior auth
Self Referral
Genetic Testing
See Specialist category
Yes
Hearing Aids
*Hearing aids are covered for AHCCCS members under age 21.
*Yes
Home Health
Obtain services by contacting Plan’s preferred Home Health provider
*Prior auth also required when Care1st is 2ndary unless Medicare is primary
*None
Care1st PRIOR AUTHORIZATION GUIDELINES Page 2 of 24
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Medical/Dental Covered Services
Special Comments
Prior Authorization Requirement
Care1st AHCCCS & DDD
Hospice/End of Life Services
Prior auth required for Care1st AHCCCS and DDD Yes
Hospital Admissions Fax notification to 602.778.8386 Yes Home Infusion Obtain services by contacting Plan’s preferred Home Infusion
provider
*Prior auth required for IVIG and Remicaid
*Prior auth required when Care1st is 2ndary unless Medicare is primary
*None
Injectables *Attachment I lists injectables that require prior auth *Yes
In-office procedures *Attachment III lists in-office procedures that require prior auth in addition to procedures noted elsewhere in this document as requiring authorization.
*Yes
Inpatient Procedures/Surgery
Yes
Insulin Pump & Tubing
Yes
Neuropsych Evaluation and Testing
Yes
Observation Fax notification to 602.778.8386 Yes
Obstetrical Care All OB care requires authorization within 30 days of pregnancy
confirmation. For high risk OB care see “Specialist”
2D OB ultrasounds (see Radiology below)
Yes
Oral Surgery Yes
Orthotics & Prosthetics Obtain items by contacting Plan’s preferred provider
*Prior auth always required unless Medicare is primary *Yes
Outpatient Rehab
*PT/OT/ST, Pulmonary Rehab, Cardiac Rehab *PT/OT/ST prior auth is required for all DDD members & AHCCCS
members under 21. *Reminder, ST is NOT covered for AHCCCS & DDD members 21 & older
*Yes
Outpatient Procedures (ASC Procedures see pg1)
All outpatient medical & diagnostic procedures require prior auth UNLESS procedure is noted elsewhere within this document as not requiring prior authorization. Injectables listed on Attachment I also require prior auth when performed in an outpatient hospital setting.
Yes
Pain Management Procedures
Epidurals (ESI & SIJ), nerve blocks, neurolysis (facet joint/MBB,RFA), spinal cord and nerve stimulators, and kyphoplasty
Yes
Pharmacy Services Non-formulary drugs. Fax request to 602.778.8387 *Excludes hemophilia factor - obtain medication by contacting CVS Specialty Pharmacy. 1.800.237.2767
*Yes
Preventive Care
Includes Well Man, Well Woman and Well Child Care *Self Referral
Radiation Oncology Includes services performed in office when performed by a
radiation oncologist No
Care1st PRIOR AUTHORIZATION GUIDELINES Page 3 of 24
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Medical/Dental Covered Services
Special Comments
Prior Authorization Requirement
Care1st AHCCCS & DDD
Radiology
CT / CTA/ MRI / MRA / PET / Hida scans / SPECT/ MUGA scans / All 3D Imaging including 3D Ultrasounds / 2D OB ultrasounds (3 or more)
Radiology procedures NOT performed at a preferred site (see Radiology Grid for list of preferred sites)
*Prior auth for the above items also required when Care1st is 2ndary unless Medicare is primary
*Yes
Skilled Nursing Facility Fax request to 602.778.8386
Yes 90 day limit per plan year
Sleep Studies
Yes
Specialist (Consults / Follow-up Visits, Procedures & Medical Services)
Chiropractic, Genetics and Perinatology
Developmental Pediatrics
Plastic Surgery - see Cosmetic and Plastic Surgery category
The specialties noted above require prior auth for all visits and medical & diagnostic procedures EXCEPT for ASC procedures that do not require prior authorization (those not listed on Attachment II).
Yes
All Sterilization Procedures
Hysterectomy (no consent form required)
Vasectomy & Tubal Ligation (notification required) with signed federal consent form.
Yes
Transplants Notification also required when Care1st is 2ndary, including a completed AHCCCS Solid Organ Transplant request sheet
Yes
Transportation
Member obtains non-emergent transportation to medically necessary services by contacting Plan’s preferred non-emergent transportation provider
**Non-emergent ambulance (including inter-facility transports to the same or lower level of care)
**Air Ambulance
**Yes
Urgent Care Member may self refer to PAR urgent care centers (see Ancillary
Provider Listing ) Self Referral
Wound Care Includes Negative Pressure Wound Therapy Wound Vacs – Obtain by contacting Plan’s preferred provider
Yes
Care1st PRIOR AUTHORIZATION GUIDELINES Page 4 of 24
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Behavioral Health Covered Services
Special Comments
Prior Authorization Requirement
DDD Care1st AHCCCS
INPATIENT SERVICES
Inpatient Behavioral Health (IPBH) Inpatient Detox (IP Detox) Residential Treatment Center (BHIF)
Responsibility of the
RBHA Yes
OUTPATIENT SERVICES (FACILITY BASED)
Partial Hospitalization Program (PHP) – Medicare only Electroconvulsive Therapy (ECT) Repetitive Transcranial Magnetic Stimulation (TMS) Intensive Outpatient Program (IOP) Residential Treatment Center (BHRF)
*No authorization required for Crisis Services
Responsibility of the RBHA
*Yes
OUTPATIENT SERVICES (NON-FACILITY BASED)
Crisis Services Responsibility of the
RBHA No
Neuropsych Evaluation & Testing Psychological Testing
Responsibility of the RBHA Yes
Residential Treatment Center (BHRF) Responsibility of the
RBHA Yes
Intensive Outpatient Program (IOP)- Services
*The following code requires auth: H2012
Responsibility of the RBHA *Yes
Psychotherapy by a Behavioral Health Professional
*No authorization required for psychotherapy for 1st 20 sessions (codes 90832, 90834, 90837,90846-90849)
Responsibility of the RBHA *Yes
Home Care Training (HCTC) *Only the following codes require auth: S5109
Responsibility of the RBHA
*Yes
Case Management (T1016) Responsibility of the
RBHA No
Psychosocial Rehabilitative Services *H2017 requires auth after 200 units Responsibility of the
RBHA *Yes
Skills Training & Development
*H2014 requires auth after 200 units
Responsibility of the RBHA
*Yes
Behavior Identification Assessment- ABA services
* 0359T-0374T require authorization Responsibility of the RBHA *Yes
Care1st PRIOR AUTHORZATION GUIDELINES Page 5 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J0129 INJECTION, ABATACEPT, 10 MG
J0135 INJECTION, ADALIMUMAB, 20 MG
J0178 INJECTION, AFLIBERCEPT, 1 MG
J0180 INJECTION, AGALSIDASE BETA, 1 MG
J0190 INJECTION, BIPERIDEN LACTATE, PER 5 MG
J0215 INJECTION, ALEFACEPT, 0.5 MG
J0220 INJECTION, ALGLUCOSIDASE ALFA, 10 MG, NOT OTHERWISE SPECIFIED
J0221 INJECTION, ALGLUCOSIDASE ALFA, (LUMIZYME), 10 MG
J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 MG
J0257 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MG
J0285 INJECTION, AMPHOTERICIN B, 50 MG
J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG
J0288 INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 MG
J0289 INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG
J0350 INJECTION, ANISTREPLASE, PER 30 UNITS
J0400 INJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MG
J0401 INJECTION, ARIPIPRAZOLE, EXTENDED RELEASE, 1 MG
J0485 INJECTION, BELATACEPT, 1 MG
J0490 INJECTION, BELIMUMAB, 10 MG
J0570 BUPRENORPHINE IMPLANT, 74.2 MG
J0571 BUPRENORPHINE, ORAL, 1 MG
J0572 BUPRENORPHINE/NALOXONE, ORAL, LESS THAN OR EQUAL TO 3 MG
J0573 BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 3 MG, BUT LESS THAN OR EQUAL TO 6 MG
J0574 BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG
J0575 BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 10 MG
J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT
J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS
J0587 INJECTION, RIMABOTULINUMTOXINB, 100 UNITS
J0588 INJECTION, INCOBOTULINUMTOXIN A, 1 UNIT
J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG
J0595 INJECTION, BUTORPHANOL TARTRATE, 1 MG
J0597 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS
J0598 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), CINRYZE, 10 UNITS
J0638 INJECTION, CANAKINUMAB, 1 MG
J0712 INJECTION, CEFTAROLINE FOSAMIL, 10 MG
J0716 INJECTION, CENTRUROIDES IMMUNE F(AB)2, UP TO 120 MILLIGRAMS
J0717 INJECTION, CERTOLIZUMAB PEGOL, 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADM
J0725 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS
J0740 INJECTION, CIDOFOVIR, 375 MG
J0775 INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG
Care1st PRIOR AUTHORZATION GUIDELINES Page 6 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS
J0881 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)
J0882 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS)
J0885 INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS
J0890 INJECTION, PEGINESATIDE, 0.1 MG (FOR ESRD ON DIALYSIS)
J0897 INJECTION, DENOSUMAB, 1 MG
J1071 INJECTION, TESTOSTERONE CYPIONATE, 1MG
J1130 INJECTION DICLOFENAC SODIUM .5
J1230 INJECTION, METHADONE HCL, UP TO 10 MG
J1290 INJECTION, ECALLANTIDE, 1 MG
J1322 INJECTION, ELOSULFASE ALFA, 1MG
J1325 INJECTION, EPOPROSTENOL, 0.5 MG
J1438 INJECTION, ETANERCEPT, 25 MG
J1439 INJECTION, FERRIC CARBOXYMALTOSE, 1MG
J1458 INJECTION, GALSULFASE, 1 MG
J1459 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)
J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC
J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG
J1557 INJECTION, IMMUNE GLOBULIN, (GAMMAPLEX), INTRAVENOUS, NON-LYOPHILIZED
J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG
J1560 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC
J1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E.G. LIQUID)
J1566 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), NOT OTHERWIS
J1568 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)
J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E.G. LIQUID)
J1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NON-LYOPHILIZED
J1575 INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN
J1599 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID)
J1600 INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG
J1602 INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE
J1630 INJECTION, HALOPERIDOL, UP TO 5 MG
J1631 INJECTION, HALOPERIDOL DECANOATE, PER 50 MG
J1640 INJECTION, HEMIN, 1 MG
J1645 INJECTION, DALTEPARIN SODIUM, PER 2500 IU
J1650 INJECTION, ENOXAPARIN SODIUM, 10 MG
J1652 INJECTION, FONDAPARINUX SODIUM, 0.5 MG
J1675 INJECTION, HISTRELIN ACETATE, 10 MICROGRAMS
J1725 INJECTION, HYDROXYPROGESTERONE CAPROATE, 1 MG
J1740 INJECTION, IBANDRONATE SODIUM, 1 MG
J1743 INJECTION, IDURSULFASE, 1 MG
Care1st PRIOR AUTHORZATION GUIDELINES Page 7 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J1744 INJECTION, ICATIBANT, 1 MG
J1745 INJECTION INFLIXIMAB, 10 MG
J1786 INJECTION, IMIGLUCERASE, 10 UNITS
J1815 INJECTION, INSULIN, PER 5 UNITS
J1817 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS
J1826 INJECTION, INTERFERON BETA-1A, 30 MCG
J1830 INJECTION INTERFERON BETA-1B, 0.25 MG
J1833 INJECTION, ISAVUCONAZONIUM, 1 MG
J1835 INJECTION, ITRACONAZOLE, 50 MG
J1930 INJECTION, LANREOTIDE, 1 MG
J1931 INJECTION, LARONIDASE, 0.1 MG
J1942 INJECTION, ARIPIPRAZOLE LAUROXIL, 1 MG
J1945 INJECTION, LEPIRUDIN, 50 MG
J1950 INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG
J2020 INJECTION, LINEZOLID, 200MG
J2170 INJECTION, MECASERMIN, 1 MG
J2182 INJECTION, MEPOLIZUMAB, 1 MG
J2212 INJECTION, METHYLNALTREXONE, 0.1 MG
J2315 INJECTION, NALTREXONE, DEPOT FORM, 1 MG
J2323 INJECTION, NATALIZUMAB, 1 MG
J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG
J2354 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS
J2355 INJECTION, OPRELVEKIN, 5 MG
J2357 INJECTION, OMALIZUMAB, 5 MG
J2358 INJECTION, OLANZAPINE, LONG-ACTING, 1 MG
J2400 INJECTION, CHLOROPROCAINE HYDROCHLORIDE, PER 30 ML
J2407 INJECTION, ORITAVANCIN, 10 MG
J2426 INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1 MG
J2502 INJECTION, PASIREOTIDE LONG ACTING, 1 MG
J2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MG
J2504 INJECTION, PEGADEMASE BOVINE, 25 IU
J2507 INJECTION, PEGLOTICASE, 1 MG
J2562 INJECTION, PLERIXAFOR, 1 MG
J2680 INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG
J2724 INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU
J2778 INJECTION, RANIBIZUMAB, 0.1 MG
J2786 INJECTION, RESLIZUMAB, 1 MG
J2794 INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG
J2840 INJECTION, SEBELIPASE ALFA, 1 MG
J2850 INJECTION, SECRETIN, SYNTHETIC, HUMAN, 1 MICROGRAM
Care1st PRIOR AUTHORZATION GUIDELINES Page 8 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J2860 INJECTION, SILTUXIMAB, 10 MG
J2941 INJECTION, SOMATROPIN, 1 MG
J3060 INJECTION, TALIGLUCERASE ALFA, 10 UNITS
J3090 INJECTION, T-E IONATE-P.A., UP TO 2 ML
J3095 INJECTION, TELEVANCIN, 10 MG
J3121 INJECTION, TESTOSTERONE ENANTHATE, 1MG
J3145 INJECTION, TESTOSTERONE UNDECANOATE, 1 MG
J3230 INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG
J3262 INJECTION, TOCILIZUMAB, 1 MG
J3285 INJECTION, TREPROSTINIL, 1 MG
J3315 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG
J3357 INJECTION, USTEKINUMAB, 1 MG
J3380 INJECTION, ISOXSUPRINE HCL, UP TO 10 MG
J3385 INJECTION, VELAGLUCERASE ALFA, 100 UNITS
J3471 INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 USP UNIT
J3472 INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1000 USP UNITS
J3486 INJECTION, ZIPRASIDONE MESYLATE, 10 MG
J3490 UNCLASSIFIED DRUGS
J3530 NASAL VACCINE INHALATION
J3535 DRUG ADMINISTERED THROUGH A METERED DOSE INHALER
J3590 UNCLASSIFIED BIOLOGICS
J7131 HYPERTONIC SALINE SOLUTION, 1 ML
J7175 INJECTION FACTOR X 1 I.U.
J7178 INJECTION, HUMAN FIBRINOGEN CONCENTRATE, 1 MG
J7196 INJECTION, ANTITHROMBIN RECOMBINANT, 50 I.U.
J7197 ANTITHROMBIN III (HUMAN), PER I.U.
J7303 CONTRACEPTIVE SUPPLY, HORMONE CONTAINING VAGINAL RING, EACH
J7304 CONTRACEPTIVE SUPPLY, HORMONE CONTAINING PATCH, EACH
J7308 AMINOLEVULINIC ACID HCL FOR TOPICAL ADMINISTRATION, 20%, SINGLE UNIT DOSAGE
J7309 METHYL AMINOLEVULINATE (MAL) FOR TOPICAL ADMINISTRATION, 16.8%, 1 GRAM
J7310 GANCICLOVIR, 4.5 MG, LONG-ACTING IMPLANT
J7311 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT
J7312 INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG
J7313 INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT, 0.01 MG
J7315 MITOMYCIN, OPTHALMIC, 0.2 MG
J7316 INJECTION, OCRIPLASMIN, 0.125 MG
J7320 HYALURONAN OR DERIVATIVE, GENVISC 850, FOR INTRA-ARTICULAR INJECTION, 1 MG
J7321 HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION
J7322 HYALURONAN OR DERIVATIVE, HYMOVIS, FOR INTRA-ARTICULAR INJECTION, 1 MG
Care1st PRIOR AUTHORZATION GUIDELINES Page 9 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J7323 HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7324 HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7325 HYALURONAN OR DERIVATIVE, SYNVISC OR SYNVISC-ONE, FOR INTRA-ARTICULAR INJECTION
J7326 HYALURONAN OR DERIVATIVE, GEL-ONE, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7327 HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
J7328 HYALURONAN OR DERIVATIVE, GEL-SYN, FOR INTRA-ARTICULAR INJECTION, 0.1 MG
J7336 CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER
J7340 CARBIDOPA 5 MG/LEVODOPA 20 MG ENTERAL SUSPENSION, 100 ML
J7342 INSTALLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG
J7502 CYCLOSPORINE, ORAL, 100 MG
J7503 CYCLOSPORINE, PARENTERAL, PER 50 MG
J7507 TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG
J7508 TACROLIMUS, EXTENDED RELEASE, ORAL, 0.1 MG
J7511 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, RABBIT, PARENTERAL, 25MG
J7515 CYCLOSPORINE, ORAL, 25 MG
J7516 CYCLOSPORIN, PARENTERAL, 250 MG
J7517 MYCOPHENOLATE MOFETIL, ORAL, 250 MG
J7518 MYCOPHENOLIC ACID, ORAL, 180 MG
J7520 SIROLIMUS, ORAL, 1 MG
J7525 TACROLIMUS, PARENTERAL, 5 MG
J7527 EVEROLIMUS, ORAL, 0.25 MG
J7599 IMMUNOSUPPRESSIVE DRUG, NOT OTHERWISE CLASSIFIED
J7605 ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED
J7606 FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMP
J7622 BECLOMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT
J7624 BETAMETHASONE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME
J7626 BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED
J7627 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME
J7631 CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED
J7632 CROMOLYN SODIUM, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME
J7633 BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED
J7634 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME
J7639 DORNASE ALFA, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED
J7641 FLUNISOLIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME
J7657 ISOPROTERENOL HCL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH
J7658 ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUND
J7659 ISOPROTERENOL HCL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUND
J7682 TOBRAMYCIN, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED
J7685 TOBRAMYCIN, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME
J7686 TREPROSTINIL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED
Care1st PRIOR AUTHORZATION GUIDELINES Page 10 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J7699 NOC DRUGS, INHALATION SOLUTION ADMINISTERED THROUGH DME
J7799 NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME
J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC, NOS
J8520 CAPECITABINE, ORAL, 150 MG
J8521 CAPECITABINE, ORAL, 500 MG
J8530 CYCLOPHOSPHAMIDE; ORAL, 25 MG
J8650 NABILONE, ORAL, 1 MG
J8655 NETUPITANT 300 MG AND PALONOSETRON 0.5 MG
J8760 ROLAPITANT, ORAL, 1 MG
J8999 PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS
J9019 INJECTION, ASPARAGINASE (ERWINAZE), 1,000 IU
J9032 INJECTION, BELINOSTAT, 10 MG
J9042 INJECTION, BRENTUXIMAB VEDOTIN, 1 MG
J9043 INJECTION, CABAZITAXEL, 1 MG
J9047 INJECTION, CARFILZOMIB, 1 MG
J9050 INJECTION, CARMUSTINE, 100 MG
J9055 INJECTION, CETUXIMAB, 10 MG
J9145 INJECTION, DARATUMUMAB, 10 MG
J9160 INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS
J9176 INJECTION, ELOTUZUMAB, 1 MG
J9179 INJECTION, ERIBULIN MESYLATE, 0.1 MG
J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG
J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG
J9205 INJECTION, IRINOTECAN LIPOSOME, 1 MG
J9214 INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS
J9215 INJECTION, INTERFERON, ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU
J9216 INJECTION, INTERFERON, GAMMA 1-B, 3 MILLION UNITS
J9217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG
J9218 LEUPROLIDE ACETATE, PER 1 MG
J9219 LEUPROLIDE ACETATE IMPLANT, 65 MG
J9225 HISTRELIN IMPLANT (VANTAS), 50 MG
J9226 HISTRELIN IMPLANT (SUPPRELIN LA), 50 MG
J9228 INJECTION, IPILIMUMAB, 1 MG
J9262 INJECTION, OMACETAXINE MEPESUCCINATE 0.01 MG
J9266 INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL
J9271 INJECTION, PEMBROLIZUMAB, 1 MG
J9295 INJECTION, NECITUMUMAB, 1 MG
J9299 INJECTION, NIVOLUMAB, 1 MG
J9301 INJECTION, OBINUTUZUMAB, 10 MG
J9302 INJECTION, OFATUMUMAB, 10 MG
Care1st PRIOR AUTHORZATION GUIDELINES Page 11 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
J9305 INJECTION, PEMETREXED, 10 MG
J9306 INJECTION, PERTUZUMAB, 1 MG
J9307 INJECTION, PRALATREXATE, 1 MG
J9310 INJECTION, RITUXIMAB, 100 MG
J9315 INJECTION, ROMIDEPSIN, 1 MG
J9325 INJECTION, TALIMOGENE LAHERPAREPVEC, PER 1 MILLION PLAQUE FORMING UNITS
J9352 INJECTION, TRABECTEDIN, 0.1 MG
J9354 INJECTION, ADO-TRASTUZUMAB EMTANSINE, 1 MG
J9355 INJECTION, TRASTUZUMAB, 10 MG
J9371 INJECTION, VINCRISTINE SULFATE LIPOSOME, 1 MG
J9395 INJECTION, FULVESTRANT, 25 MG
J9400 INJECTION, ZIV-AFLIBERCEPT, 1 MG
J9600 INJECTION, PORFIMER SODIUM, 75 MG
J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS
90378 RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR
90393 VACCINIA IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE
90749 UNLISTED VACCINE/TOXOID
A9515 CHOLINE C-11, DIAGNOSTIC, PER STUDY DOSE UP TO 20 MILLICURIES
A9530 IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE
A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40 MIL
A9587 GALLIUM GA-68, DOTATATE, DIAGNOSTIC, 0.1 MILLICURIE
A9588 FLUCICLOVINE F-18, DIAGNOSTIC, 1 MILLICURIE
A9598 POSITRON EMISSION TOMOGRAPHY RADIOPHARMACEUTICAL, DIAGNOSTIC, FOR NON-TUMOR IDENTIFICATION, NOT OTHERWISE CLASSIFIED
A9606 RADIUM RA-223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE
A9699 RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE CLASSIFIED
C9140 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (AFSTYLA), 1 IU
C9275 INJECTION, HEXAMINOLEVULINATE HYDROCHLORIDE, 100 MG, PER STUDY DOSE
C9460 INJECTION, CANGRELOR, 1 MG
C9482 INJECTION, SOTALOL HYDROCHLORIDE, 1 MG
C9483 INJECTION, ATEZOLIZUMAB, 10 MG
C9497 LOXAPINE, INHALATION POWDER, 10 MG
G0429 DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)
P9048 INFUSION, PLASMA PROTEIN FRACTION (HUMAN), 5%
Q0138 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG
Q0139 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG
Q0144 AZITHROMYCIN DIHYDRATE, ORAL, CAPSULES/POWDER, 1 GRAM
Q0174 THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC,
Q0180 DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR
Care1st PRIOR AUTHORZATION GUIDELINES Page 12 of 24
ATTACHMENT I: J Codes and Other Injectables Requiring Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Code Description
Q0181 UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS
Q0515 INJECTION, SERMORELIN ACETATE, 1 MICROGRAM
Q2004 IRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, FOR EXAMPLE RENACIDIN,
Q2017 INJECTION, TENIPOSIDE, 50 MG
Q2043 SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP-GM
Q2049 INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, IMPORTED LIPOSOMAL, IMPORTED
Q2050 INJECTION, DOXORUBICIN HYDROCHLORIDE, LIPOSOMAL, NOT OTHERWI
Q3027 INJECTION, INTERFERON BETA-1A, 1 MCG FOR INTRAMUSCULAR USE
Q3028 INJECTION, INTERFERON BETA-1A, 1 MCG FOR SUBCUTANEOUS USE
Q4074 ILOPROST, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMIN
Q4081 INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)
Q4082 DRUG OR BIOLOGICAL, NOT OTHERWISE CLASSIFIED, PART B DRUG COMPETITIVE ACQUISITIO
Q4100 SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED
Q4101 APLIGRAF, PER SQUARE CENTIMETER
Q4102 OASIS WOUND MATRIX, PER SQ CM
Q4104 INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETER
Q4105 INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARE CENTIMETER
Q4106 DERMAGRAFT, PER SQUARE CENTIMETER
Q4107 GRAFTJACKET, PER SQUARE CENTIMETER
Q4108 INTEGRA MATRIX, PER SQUARE CENTIMETER
Q4110 PRIMATRIX, PER SQUARE CENTIMETER
Q4111 GAMMAGRAFT, PER SQ CM
Q4116 ALLODERM, PER SQUARE CENTIMETER
Q4121 THERASKIN, PER SQUARE CENTIMETER
Q4123 ALLOSKIN RT, PER SQUARE CENTIMETER
Q4149 EXCELLAGEN, 0.1 CC
Q4166 CYTAL PER SQ CM
Q4167 TRUSKIN PER SQ CM
Q4168 AMNIOBAND 1 MG
Q4169 ARTACENT WOUND PER SQ CM
Q4170 CYGNUS PER SQ CM
Q4171 INTERFYL 1 MG
Q4172 PURAPLY OR PURAPLY AM PER SQ C
Q4173 PALINGEN OR PALINGEN XPLUS PER
Q4174 PALINGEN OR PROMATRX 0.36 MG P
Q4175 MIRODERM PER SQ CM
Q5102 INJECTION, INFLIXIMAB, BIOSIMILAR, 10 MG
Q9950 INJECTION, SULFUR HEXAFLUORIDE LIPID MICROSPHERES, PER ML
S0119 ONDANSETRON, ORAL, 4 MG
S0190 MIFEPRISTONE, ORAL, 200 MG
S0191 MISOPROSTOL, ORAL, 200 MCG
Care1st PRIOR AUTHORZATION GUIDELINES Page 13 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 10040* Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) 11200* Removal of skin tags, multiple fibrocutaneous tags, any area: up to and including 15 lesions
11201* Each additional 10 lesions, or part thereof (list separately in addition to code for primary procedure)
11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin 6.0 sq cm or less 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin 6.1 to 20.0 sq cm
11922* Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin; each additional 20.0 sq cm
11950 Subcutaneous injection of filling material (eg. Collagen); 1 cc or less 11951 Subcutaneous injection of filling material (eg. Collagen); 1.1 to 5.0 cc
11952 Subcutaneous injection of filling material (eg. Collagen); 5.1 to 10.0 cc 11954 Subcutaneous injection of filling material (eg. Collagen); over 10.0 cc
15775 Punch graft for hair transplant; 1 to 15 punch grafts
15776 Punch graft for hair transplant; more than 15 punch grafts 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
15781 Dermabrasion; segmental, face
15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (eg, tattoo removal)
15786* Abrasion; single lesion (eg, keratosis, scar)
15787* Abrasion; single lesion (eg, keratosis, scar) each additional 4 lesions or less 15788* Chemical peel, facial; epidermal
15789 Chemical peel, facial; dermal 15792* Chemical peel, nonfacial; epidermal
15793* Chemical peel, nonfacial; dermal
15819 Cervicoplasty 15820 Blepharoplasty, lower eyelid
15821 Blepharoplasty,with extensive herniated fat pad
15822 Blepharoplasty, upper eyelid 15823 Blepharoplasty, with execessive skin weighting down lid
15824 Rhytidectomy; forehead
15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines
15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomyl; superficial musculoaponeurotic system (SMAS) flap
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock 15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
15847* Removal of excess abdominal tissue 15876 Suction assisted lipectomy; head and neck
15877 Suction assisted lipectomy; trunk
15878 Suction assisted lipectomy; upper extremity 17340* Cryotherapy (CO2 slush, liquid N20) for acne
17360* Chemical exfoliation for acne (eg, acne past, acid)
17380 Electrolysis epilation, each 30 minutes 19316 Mastopexy
19318 Reduction mammaplasty
Care1st PRIOR AUTHORZATION GUIDELINES Page 14 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 19324 Mammaplasty, augmentation; without prosthetic implant 19325 Mammaplasty, augmentation; with prosthetic implant
19328 Removal of intact mammary implant
19330 Removal of mammary implant material 19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19355 Correcton of inverted nipples 21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service
21076 Impression and custom preparation; surgical obturator prosthesis 21077 Impression and custom preparation; orbital prosthesis
21079 Impression and custom preparation; interim obturator prosthesis
21080 Impression and custom preparation; definitive obturator prosthesis 21081 Impression and custom preparation; mandibular resection prosthesis
21082 Impression and custom preparation; palatal augmentation prosthesis
21083 Impression and custom preparation; palatal lift prosthesis 21084 Impression and custom preparation; speech aid prosthesis
21085 Impression and custom preparation; oral surgical splint
21086 Impression and custom preparation; auricular prosthesis 21087 Impression and custom preparation; nasal prosthesis
21088 Impression and custom preparation; facial prosthesis 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121 Genioplasty; sliding osteotomy, single piece
21122 Genioplasty; sliding osteotomies, 2 or more osteotomies 21123 Genioplasty; sliding, augmentation with interpositional bone grafts
21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpostional 21137 Reduction forehead; contouring only
21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
21139 Reduction forehead; contouring and setback of anterior frontal sinus wall 21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome
21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)
21242 Arthroplasty, temporomandibular joint, with allograft
21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement 21270 Malar augmentation, prosthetic material
21280 Medial canthopexy (separate procedure)
21282 Lateral canthopexy 22853* Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg,
screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each inter 22854* Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring
(eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete)
22859* Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary
22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
22868* Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)
22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
22870* Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)
Care1st PRIOR AUTHORZATION GUIDELINES Page 15 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 24370 Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component 24371 Humeral or ulnar component
26560 Repair of syndactyly (web finger) each web space; with skin flaps
26561 Repair of syndactyly (web finger) each web space; with skin flaps and grafts 26562 Repair of syndactyly (web finger) each web space; metacarpal, each
26580 Repair cleft hand
26587 Reconstruction of polydactylous digit, soft tissue and bone 26590 Repair macrodactylia, each digit
28150 Phalangectomy, toe, each toe 28153 Resection, condyle(s), distal end of phalanx, each toe
28160 Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each
28280 Syndactylization, toes (eg, webbing or Kelikian type procedure) 28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant
28292 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method
28296 Correction, hallux valgus (bunion), with metatarsal osteotomy
28297 Correction, hallux valgus (bunion), with Lapidus-type procedure 28298 Correction, hallux valgus (bunion), by phalanx osteotomy
28299 Correction, hallux valgus (bunion), by double osteotomy
28344 Reconstruction, toe(s); polydactyly 28345 Reconstruction, toe(s); syndactyly, with or without skin graft (s) each web
28899 Unlisted procedure, foot or toes
29750 Wedging of clubfoot cast
30120 Excision or surgical planing of skin or nose for rhinophyma
30124 Excision dermoid cyst, nose; simple skin, subcutaneous 30125 Excision dermoid cyst, nose; complex, under bone or cartilage
30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420 Rhinoplasty, primary; including major septal repair
30430 Rhinioplasty, secondary; minor revision (small amount of nasal tip work) 30435 Rhinioplasty, secondary; intermediate revision (bony work with osteotomies)
30450 Rhinioplasty, secondary; major revision (nasal tip work and osteotomies)
30460 Rhinioplasty, for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only 30462 Rhinioplasty, for nasal deformity secondary to congenital cleft lip or palate, including columellar lengthening; tip, septum
31299** Unlisted procedure, accessory sinuses
32998* Ablation therapy for reduction or eradication of 1 or more pulmonary tumor (s) including pleura or chest wall 36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous,
mechanochemical; first vein treated 36474* Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous,
mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition
38205** Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic 38243 Hematopoietic progenitor cell (HPC); HPC boost
40700 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral 40701 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 –stage procedure
40702 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages
40720 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure 40761 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type)
41899** Unlisted procedure, dentoalveolar structures
42200 Palatoplasty for cleft palate, soft and/or hard palate only 42205 Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only
Care1st PRIOR AUTHORZATION GUIDELINES Page 16 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 42210 Palatoplasty for cleft palate, with bone graft to alveolar ridge (includes obtaining graft) 42215 Palatoplasty for cleft palate, major revision
42220 Palatoplasty for cleft palate; secondary lengthening procedure
42225 Palatoplasty for cleft palate, attachment pharyngeal flap 42226 Lengthening of palate, and pharyngeal flap
42227 Lengthening of palate, with island flap
43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed
54150 Circumcision, using clamp or other device with regional dorsal penile or ring block 54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)
54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (older than 28 days of age)
54162 Lysis or excision of penile post-circumcision adhesions 54163 Repair incomplete circumcision
54164 Frenulotomy of penis
54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 54304 Operation on penis for correction of chordee/first stage hypospadias repair with/without transplantation
54308 Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm 54312 Urethroplasty for second stage hypospadias repair (including urinary diversion); greater than 3 cm
54316 Urethroplasty for second stage hypospadias repair with free skin graft obtained from site other than genitalia
54318 Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair) 54322 1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement
54324 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps
54326 1-stage distal hypospadias repair with urethroplasty by local skin flaps and mobilization of urethra with/without circumcision 54328 1-stage distal hypospadias repair with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin
graft patch, and/or island flap with/without circumcision 54332 1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of
skin graft tube and/or island flap
54336 1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap
54340 Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple
54344 Repair of hypospadias complications requiring mobilization of skin flaps and urethroplasty with flap or patch graft 54348 Repair of hypospadias complications requiring extensive dissection and urethroplasty with flap, patch or tubed graft
54352 Repair of hypospadias cripple requiring extensive dissection/excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts
54360 Plastic operation on penis to correct angulation
54380 Plastic operation on penis for epispadias distal to external sphincter; 54385 Plastic operation on penis for epispadias distal to external sphincter; with incontinence
54400 Insertion of penile prosthesis; non-inflatable (semi-rigid)
54401 Insertion of penile prosthesis; inflatable (self-contained) 54405 Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir
54406 Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis 54408 Repair of component(s) of a multi-component, inflatable penile prosthesis
54410 Removal/replacement of all component of multi-component, inflatable penile prosthesis at the same operative session
54415 Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis 54416 Removal/replacement of non-inflatable (semi-rigid)/inflatable (self-contained) penile prosthesis at the same operative session
54420 Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral
54435 Corpora cavernosa-glans penis fistulization (eg, biospsy needle, Winter procedure, rongeur, or punch) for priapism 54440 Plastic operation of penis for injury
55400 Vasovasostomy, vasovasorrhaphy
56800 Plastic repair of introitus 56805 Clitoroplasty for intersex state
Care1st PRIOR AUTHORZATION GUIDELINES Page 17 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 57156 Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy 57260 Combined anteroposterior colporrhaphy
57265 Combined anteroposterior colporrhaphy; with enterocele repair
57291 Construction of artificial vagina; without graft 57295 Revision (including removal) of prosthetic vaginal graft; vaginal approach
58321 Artificial insemination; intra-cervical
58322 Artificial insemination; intra-uterine 58323 Sperm washing for artificial insemination
58345 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency 58350 Chromotubation of oviduct, including materials
58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
58672 Laparoscopy, surgical; with fimbrioplasty 58673 Laparoscopy, surgical; with salpingostomy
58674 Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency
58970 Follicle puncture for oocyte retrieval, any method 58974 Embryo transfer, intrauterine
58976 Gamete, zygote, or embryo intrafallopian transfer, any method
62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)
62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance
62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance
62350 Implantation, revision/repositioning of tunneled intrathecal/epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy
62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump
62362 Implantation/replacement of device for intrathecal/epidural drug infusion; programmable pump, including preparation of pump, with or without programming
62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar
63650 Percutaneous implantation of neurostimulator electrode array, epidural
63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural
Care1st PRIOR AUTHORZATION GUIDELINES Page 18 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch
64402* Injection, anesthetic agent; facial nerve
64405 Injection, anesthetic agent; greater occipital nerve 64408 Injection, anesthetic agent; vagus nerve
64410 Injection, anesthetic agent; phrenic nerve
64413 Injection, anesthetic agent; cervical plexus 64415 Injection, anesthetic agent; brachial plexus, single
64416 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)
64417 Injection, anesthetic agent; axillary nerve 64418 Injection, anesthetic agent; suprascapular nerve
64420 Injection, anesthetic agent; 18ntercostals nerve, single 64421 Injection, anesthetic agent; 18ntercostals nerves, multiple, regional block
64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves
64430 Injection, anesthetic agent; pudendal nerve 64435 Injection, anesthetic agent; paracervical (uterine) nerve
64445 Injection, anesthetic agent; sciatic nerve, single
64446 Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) 64447 Injection, anesthetic agent; femoral nerve, single
64448 Injection, anesthetic agent; femoral nerve, continous infusion by catheter (including catheter placement)
64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continous infusion by catheter (including catheter placement) 64450 Injection, anesthetic agent; other peripheral nerve or branch
64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg. Morton’s neuroma) 64461 Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)
64462* Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure)
64463 Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)
64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging; cervical or thoracic
64480* Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging; cervical or thoracic, each additional level 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging; lumbar or sacral, single level
64484* Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging; lumbar or sacral each additional level 64490 Injection(s) facet, cervical or thoracic; single level
64491* Injection(s) facet, cervical or thoracic; second level
64492* Injection(s) facet, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary proc. 64493 Injection(s) facet, lumbar or sacral; single level
64494* Injection(s) facet, lumbar or sacral; second level (List separately in addition to code for primary procedure)
64495* Injection(s) facet, lumbar or sacral; third and any additional levels (List separately in addition to code for primary procedure) 64505 Injection, anesthetic agent; sphenopalatine ganglion
64508 Injection, anesthetic agent; carotid sinus (separate procedure)
64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 64517 Injection, anesthetic agent; superior hypogastric plexus
64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring 64553 Percutaneous implantation of neurostimulator electrodes; cranial nerve
64555 Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64561 Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
64565 Percutaneous implantation of neurostimulator electrodes; neuromuscular
64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming 64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
64569 Revision or replacement of cranial nerve (eg,vagus nerve) neurostimulator electrode array including connection to existing pulse generator
64575 Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)
Care1st PRIOR AUTHORZATION GUIDELINES Page 19 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 64580 Incision for implantation of neurostimulator electrodes; neuromuscular 64581 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement)
64585 Revision or removal of peripheral neurostimulator electrode array
64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch
64605 Destruction by neurolytic agent, trigeminal nerve; 2nd and 3rd division branches at foramen ovale 64610 Destruction by neurolytic agent, trigeminal nerve; 2nd and 3rd division branches at foramen ovale under radiologic monitoring
64615 Chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) 64617 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle
electromyography, when performed 64620 Destruction by neurolytic agent, 19ntercostals nerve
64630 Destruction by neurolytic agent; pudendal nerve
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634* Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
64636* Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint
64640 Destruction by neurolytic agent; other peripheral nerve or branch
64642 Chemodenervation of one extremity; 1-4 muscle(s)
64643* Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (list separately in addition to code for primary procedure) 64644 Chemodenervation of one extremity; 5 or more muscles
64645* Chemodenervation of one extremity; each additional extremity, 5 or more muscles (list separately in addition to code for primary procedure)
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)
64647 Chemodenervation of trunk muscle(s); 6 or more muscles 64680 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus
64681 Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus
65710 Keratoplasty (corneal transplant); anterior lamellar 65730 Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia)
65750 Keratoplasty (corneal transplant); penetrating (in aphakia)
65755 Keratoplasty (corneal transplant); penetrating (in pseudophakia) 65756 Keratoplasty (corneal transplant); endothelial
65770 Keratoprosthesis
65772 Corneal relaxing incision for correction of surgically induced astigmatism 65775 Corneal wedge resection for correction of surgically induced astigmatism
65785 Implantation of intrastromal corneal ring segments 67229 Retinopathy preterm infant photo/cryotherapy
67820* Correction of trichiasis; epilation, by forceps only
67825 Correction of trichiasis; epiliation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery
67830 Correction of trichiasis; incision of lid margin
67835 Correction of trichiasis; incision of lid margin, with free mucous membrane graft
67880 Construction of intermarginal adhesions median tarsorrhaphy, or canthorrhaphy;
67882 Construction of intermarginal adhesions median tarsorrhaphy, or canthorrhaphy; with transportation of tarsal plate
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
67901 Repair of blepharoptosis; frontails mucscle technique with suture or other material (eg, banked fascia)
67902 Repair of blepharoptosis; frontails mucscle technique with autologous fascial sling (includes obtaining fascia)
Care1st PRIOR AUTHORZATION GUIDELINES Page 20 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
Code Description 67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908 Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection (eg, Fasanella-Servat type)
67909 Reduction of overcorrection of ptosis
67911 Correction of lid retraction
67912 Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight)
67914 Repair of entropion; suture 67915 Repair of entropion; thermocauterization
67916 Repair of entropion; excision tarsal wedge
67917 Repair of entropion; extensive (eg, tarsal strip operations) 67921 Repair of entropion; suture
67922 Repair of entropion; thermocauterization
67923 Repair of entropion; excision tarsal wedge 67924 Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation)
67950 Canthoplasty (reconstruction of canthus) 67961 Excision and repair of eyelid up to ¼ of lid margin
67966 Excision and repair of eyelid over ¼ of lid margin
67971 Reconstuction of eyelid, first stage up to 2/3 of eyelid, 67973 Reconstruction total lower eyelid, first stage
67974 Reconstruction total upper eyelid, first stage
67975 Reconstruction eyelid, second stage 69930 Cochlear device implantation, with or without mastoidectomy
74742* Transcervical catheterization of fallopian tube, radiological supervision and interpretation
76948* Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 0100T* Placement retinal prosthesis, implantation of intra-ocular retinal electrode array/with vitrectomy
0101T* Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy 0102T* Extracorporeal shock wave, by physician with anesthesia other than local, with lateral humeral epicondyle
0200T* Sacroplasty/unilateral injuection(s) with balloon or mechanical device
0201T* Sacroplasty/bilateral injuection(s) with balloon or mechanical device 0213T* Facet injection(s) with ultra-sound guidance, cervical or thoracic level, single level
0214T* Facet injection(s) with ultra-sound guidance, cervical or thoracic level, second level
0215T* Facet injection(s) with ultra-sound guidance, cervical or thoracic level, third and additional levels 0216T* Facet injection(s) with ultra-sound guidance, lumbar and sacral level, single level
0217T* Facet injection(s) with ultra-sound guidance, lumbar and sacral level, second level
0218T* Facet injection(s) with ultra-sound guidance, lumbar and sacral level, third and additional levels 0228T* Epidural injection, with guidance, cervical or thoracic level
0229T* Epidural injection, with guidance, cervical or thoracic, each additional level 0230T* Epidural injection, with guidance, lumbar or sacral, single level
0231T* Epidural injection, with guidance, lumbar or sacral, each additional level
0232T* Injection plasma, any site, with guidance, harvesting and preparation included 0394T High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry
0395T High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry
0437T Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure)
0439T Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure)
0440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441T Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve 0442T Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
0443T Real time spectral analysis of prostate tissue by fluorescence spectroscopy
Care1st PRIOR AUTHORZATION GUIDELINES Page 21 of 24
ATTACHMENT II: ASC Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
*AHCCCS considers the service to be inclusive of the primary procedure when performed in an ASC **CMS does not allow service to be performed in ASC
0444T Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
0445T Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral
0446T Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training 0447T Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision
0448T Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation
0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device
0450T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedure)
0451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable va
0452T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal
0453T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano-electrical skin interface
0454T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode
0455T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes)
0456T Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal
0457T Removal of permanently implantable aortic counterpulsation ventricular assist system; mechano-electrical skin interface
0458T Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode 0459T Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano-electrical skin interface
and electrodes
0460T Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode 0461T Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device
0462T Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including revi
0463T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day
0464T Visual evoked potential, testing for glaucoma, with interpretation and report
0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication)
0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure)
0467T Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator 0468T Removal of chest wall respiratory sensor electrode or electrode array
C1889 Implantable/insertable device for device intensive procedure, not otherwise classified
C9727 Insertion of implants into the soft palate, minimum of 3 implants C9748 Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) thermal therapy
Care1st PRIOR AUTHORZATION GUIDELINES Page 22 of 24
ATTACHMENT III: In-Office Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Category III 15576 17360
0437T 15600 17380
0438T 15610 17999
0439T 15620 19499
Integumentary 15630 Musculoskeletal
11000 15650 20974
11920 15730 20975
11921 15731 20979
11922 15733 20999
11950 15734 21011
11951 15736 21012
11952 15738 21013
11954 15740 21014
11960 15775 21016
11970 15776 21073
11971 15777 21076
11980 15780 21077
14000 15781 21079
14001 15782 21080
14020 15783 21081
14021 15786 21082
14040 15787 21083
14041 15788 21084
14060 15789 21085
14061 15792 21086
14301 15793 21087
14302 15819 21088
14350 15820 21089
15050 15821 21116
15100 15822 21299
15101 15823 21499
15120 15824 21899
15121 15825 22510
15200 15826 22511
15201 15827 22512
15220 15828 22513
15221 15829 22514
15240 15830 22515
15241 15832 22899
15260 15833 22999
15261 15834 23929
15271 15835 24999
15272 15836 25999
15273 15837 26989
15274 15838 27299
15275 15839 27599
15276 15786 27899
15277 15787 28899
15278 15788 29750
15570 15789 29799
15572 15999 29999
15574 17340
Care1st PRIOR AUTHORZATION GUIDELINES Page 23 of 24
ATTACHMENT III: In-Office Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
Respiratory 42999 59012
30120 43286 59015
30124 43287 59030
30400 43288 59100
30430 43289 59200
30999 43499 59320
31241 43659 59325
31253 43999 59400
31255 44238 59425
31257 44799 59426
31298 44899 59430
31299 44979 59510
31599 45399 59525
31899 45499 59610
32553 45999 59618
32999 46999 59812
Cardiovascular, Hemic, Lymphatic 47379 59820
33999 47399 59821
36299 47579 59830
36468 47999 59840
36470 48999 59841
36471 49329 59850
36465 49659 59851
36466 49999 59852
36473 Urinary 59855
36474 50549 59856
36475 50949 59857
36478 51999 59898
36482 52441 59899
36483 52442 Endocrine
37501 53899 60659
37765 Genital 60699
37766 54699 Nervous System
37799 55200 64400
38129 55250 62320
38573 55300 62321
38589 55450 62322
38999 55559 62323
39499 55899 62324
39599 55920 62325
Digestive 58346 62326
40799 58565 62327
40899 58578 62380
41019 58579 64402
41599 58600 64405
41820 58605 64408
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Care1st PRIOR AUTHORZATION GUIDELINES Page 24 of 24
ATTACHMENT III: In-Office Procedures that Require Prior Authorization
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
ALL BY-REPORT, NEW AND RE-SEQUENCED CODES REGARDLESS OF PLACE OF SERVICE REQUIRE PRIOR AUTHORIZATION ALL NON-EMERGENT SERVICES PROVIDED BY A NON-PAR PROVIDER OR FACILITY REQUIRE PRIOR AUTHORIZATION
Effective 1/1/2019 These guidelines are available at www.care1staz.com
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