Prior Authorization Change Summary Effective September 1, 2024
Date: 06/12/24
Louisiana Healthcare Connections is sharing with providers prior authorization change summary that will be effective September 1, 2024.
We are is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process anitiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes 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. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.
Effective September 1st, 2024, the following are changes to prior authorization requirements:
**8/22/24- A previsous version of this notice included codes E0260 and E0784 with changes. These code will not be impacted.**
Service Category | PA Rule | Services | Procedure Codes |
Behavioral Health | PA Required | Treatment Services | 90867, 90868, 90869, 90870, S9480 |
Substance Abuse Treatment | H0008, H0009, H0010 | ||
Therapy | H2019, H2020 | ||
No PA Required | Behavior Health Assessment | 96156 | |
Therapy | 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171 | ||
Cardiovascular | PA Required | Cardiovascular Procedures | 33285, 33289, 33548, 33999, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37243, 37799, 0237T, 0238T, 0267T, 0268T, 0269T, 0483T, C9765 |
Cardiac Other | 93799 | ||
Drug Codes | PA Required | Specialty Drugs | J0585, J0586, J1096, J1729, Q2028, S0128 |
Other Drugs | J7328 | ||
Chemotherapeutics | J9027, J9034, J9039, J9043, J9065, J9395 | ||
Medications | S0189 | ||
No PA Required | Diabetic Drugs and Supplies | A9277, A9278, E2100 | |
Nutritional Services | B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B5000, B5100, B5200 | ||
Specialty Drugs | J0121, J0205, J0207, J0215, J0890, J2425, J3095, J3489, J9155, Q2026, S0172, S0175 | ||
Chemotherapeutics | A9542, J0594, J9000, J9025, J9030, J9040, J9045, J9060, J9070, J9098, J9100, J9120, J9130, J9150, J9151, J9171, J9175, J9178, J9181, J9185, J9190, J9200, J9201, J9206, J9207, J9208, J9209, J9230, J9245, J9263, J9267, J9268, J9280, J9320, J9340, J9351, J9360, J9370, J9390, J9600, Q2049 | ||
Other Drugs | J7310, J7315, J7500, J7513, J7517, J7518, J7525, J8530, J8562, J8700 | ||
Durable Medical Equipment
Durable Medical Equipment
Durable Medical Equipment | PA Required | Cardiac Devices | C1899 |
Supplies & Devices | 0226T, C1813, E0486, K0900 | ||
Mobility Devices | E0639 | ||
Wheelchairs | E0983, E1009, E1239, E2322, E2609, E2617 | ||
Orthotics & Prosthetics | E1830, L1845 | ||
Skin Grafts | C9354, C9358, C9360, C9363, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4115, Q4116, Q4117, Q4118, Q4121, Q4132, Q4136, Q4137, Q4150, Q4151, Q4152, Q4155, Q4158, Q4159, Q4160, Q4166, Q4168, Q4170, Q4171, Q4173, Q4174, Q4181, Q4183, Q4186, Q4188, Q4189, Q4194, Q4195, Q4196, Q4197, Q4201, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4230, Q4239, Q4249 | ||
Other Services | S1002 | ||
No PA required if member < 21 years at DOS | Orthotics & Prosthetics | L1907, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1990 | |
No PA Required
No PA Required | Infusion Pump and Supplies | A4305, E0781, E0785, E0786, K0455 | |
Neurostimulators | A4555, C1822, C1823, E0720, E0730, E0744, E0746, E0755, E0761, E0762, E0765, E0769, L8681, L8684, L8689, S8130, S8131 | ||
Equipment, Devices & Accessories | A4210, A4870, A4890, A8003, A9279, E0190, E0749, E0849, E0912, E0953, E1510, E1590, E1592, E1594, E1620, E1630, E1632, E1635, E1699, E2000, L8610, L8612, L8631, L8659, L8670, S9335, S9339 | ||
Nutritional Services | B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B9002, B9004, B9006, B9998, B9999, E0791, S9433 | ||
Mobility Devices | E0147, E0148, E0149, E630, E0635, E0636 | ||
Beds | E0186, E0251, E0255, E0261, E0265, E0266, E0277, E0292, E0293, E0294, E0295, E0296, E0301, E0302, E0303, E0304, E0371, E0372, E0373 | ||
Respiratory Devices & Supplies | E0430, E0431, E0443, E0445, E0455, E0480, E0500, E0550, E0565, E0574, E0601, E0618, E0619, E1391, K0730 | ||
Breast Pump | E0604 | ||
Cardiac Devices | E0615, K0609 | ||
Wheelchairs | E0954, E0958, E1030, E1031, E1037, E1050, E1060, E1070, E1084, E1086, E1087, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1140, E1150, E1160, E1195, E1222, E1224, E1226, E1231, E1240, E1250, E1260, E1280, E1285, E1290, E1295, E1296, E2202, E2203, E2204, E2228, E2291, E2292, E2293, E2294, E2359, E2366, E2368, E2378, E2611, E2612, E2628, K0001, K0002, K0003, K0004, K0006, K0007 | ||
Orthotics & Prosthetics | E1801, E1806, E1811, E1818, E1841, L0112, L0170, L0190, L0200, L0456, L0458, L0460, L0462, L0468, L0469, L0470, L0480, L0488, L0490, L0491, L0492, L0635, L0637, L1001, L1200, L1230, L1300, L1640, L1680, L1686, L1690, L1730, L1860, L2106, L2108, L2114, L2116, L2136, L2330, L2340, L2350, L2510, L2520, L2525, L2526, L2540, L2570, L2580, L2627, L2628, L3160, L3230, L3330, L3760, L3915, L3916, L3960, L3962, L3967, L3981, L4000, L4130, L4205, L5150, L5400, L5410, L5430, L5450, L5460, L5616, L5617, L5626, L5628, L5630, L5631, L5638, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5650, L5651, L5652, L5653, L5661, L5665, L5671, L5673, L5677, L5679, L5681, L5682, L5683, L5714, L5716, L5785, L5790, L5810, L5811, L5812, L5816, L5818, L5822, L5828, L5859, L5920, L5940, L5950, L5960, L5962, L5964, L5975, L5976, L5982, L5984, L5986, L5990, L6388, L6623, L6625, L6628, L6647, L6686, L6687, L6688, L6689, L6692, L6693, L6698, L6707, L6708, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6883, L6884, L6885, L6895, L6905, L6940, L6945, L7366, L7368, L7404, L7405, L7900, L8030, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8691 | ||
Wound Care | A6501, A6507, A6511, E2402 | ||
Gastroenterology | PA Required | Digestive System Procedures | 43659, 44799, 44899, 45399, 45499, 45999, 46999, 47399, 47999, 48999, 91299, 0184T, S2080 |
No PA Required | Bariatric Surgery | 43648, 43771, 43772, 43773, 43774, 43882, 43886, 43887, 43888, 95980, 95981, 95982, S2083 | |
Genitourinary Procedures | PA Required | Genitourinary Procedures | 50549, 51999, 53899, 54401, 54405, 54699, 55899, 58345, 0404T |
Gender Reassignment | 55970, 55980 | ||
Infertility Treatments | 58322, 58323, 58350, 58750, 58760, 58970 | ||
PA only required if billed with diagnosis of gender dysphoria | Genitourinary Procedures | 53410, 53415, 53420, 53425, 53430, 53460, 54125, 54400, 54406, 54408, 54410, 54411, 54415, 54416, 54420, 54520, 54660, 54690, 55175, 55180, 55866, 55870, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57292, 57295, 57335, 57426, 58661, 58940, 58999 | |
Hysterectomies | 58150, 58180, 58260, 58262, 58263, 58270, 58275, 58290, 58291, 58292, 58297, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573 | ||
Sterilizations | 58720 | ||
No PA Required |
Hysterectomies | 58152, 58200, 58210, 58240, 58280, 58545, 58546, 58548, 58575, 58951, 58952, 58953, 58954, 58956, 59525 | |
Genitourinary Procedures | 50548, 54680 | ||
Hearing Services | No PA Required | Implants and Supplies | L8615, L8616, L8617, L8618, L8621, L8623, L8624, L8625, L8628, L8629, L8693 |
Hearing Aids | V5090, V5110, V5150, V5160, V5190, V5200, V5212, V5240, V5241, V5262, V5263, V5265, V5267, V5268, V5269, V5270, V5271, V5272, V5275, V5281, V5282, V5283, V5284, V5285, V5288, V5289, V5290 | ||
Home Services | PA Required | Nursing Services | G0493, G0494, G0495, G0496, S9351, T1000 |
No PA Required | Home Therapy | 99500, 99501, 99502, 99503, 99504, 99505, 99506, 99507, 99509, 99510, 99511, 99512, S9097, S9098 | |
Home Visit | G0162, S5181, S9212, T1028 | ||
Case Management | S0270, S0272 | ||
Infusion Services | S5035, S5036 | ||
Education Services | S5110 | ||
Hospice | PA Required | Hospice Services | Q5005, T2045, T2046 |
No PA Required | Hospice Services | 657, 99377, 99378, G0182, Q5001, Q5002, Q5003, Q5004, Q5006, Q5007, Q5008, Q5009, Q5010, S0255, S0271, S9126, T2042 | |
Imaging Services | PA Required | Nuclear Medicine | 78999 |
No PA Required | MRI/PET Imaging | 70557, 70558, 70559, G0252 | |
Infertility Treatments | PA Required | Reproductive Medicine | 89254, 89258, 89259, 89261, 89337 |
Laboratory | PA Required | Genetic Testing | 81235, 81519, S3841, S3845, S3852, S3854, S3865, S3866, S3870 |
Pathology | 81268 | ||
Multianalyte Assays | 81510 | ||
Microbiology | 87999 | ||
Drug Tests | G0482, G0483 | ||
No PA Required | Genetic Testing | 81200, 81209, 81242, 81244, 81250, 81252, 81253, 81256, 81258, 81330, 81331, 81332, 81333, 81336, 81337, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81383, 86812, 86813, 86816, 86817, 86821, 86825, 86826, 86828, 86829, 86830, 86831, 86832, 86833, 86834, 86835, 87483, 88230, 88233, 88235, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 0016U, 0174U, 0219U | |
Multianalyte Assays | 81535, 81536 | ||
Lab Tests | 0014M, 0202U | ||
Maternity Services | PA Required | Maternity Care & Delivery | 59899 |
Other Medical Services | PA Required | Clinical Trial Services | S9992, S9994, S9996 |
Respite Services | T1005 | ||
No PA Required | Hyperbaric Oxygen Therapy | 99183 | |
Unskilled Respite Care | S5150 | ||
Pain Management | PA Required | Injections | 62263, 62264, 62281, 62282, 64405, 64494, 64600, 64634, 64636, 64640 |
PA not required if billed on same day as other surgical procedure | Injections | 64451, 64454, 64461, 64462, 64463, 64480, 64492, 64495 | |
Neurology & Neuromuscular Procedures | 64625 | ||
No PA Required | Injections | 20552, 20553, 62280, 62324, 62325, 62326, 62327, 64486, 64487, 64488, 64489, 64505, 64620, 64630, 64632, 64680, 64681 | |
Physical Medicine | PA Required | Occupational Therapy Services | G0129 |
Sensory Testing | 0106T, 0107T, 0108T, 0109T | ||
No PA Required | Therapy Services | G2169, S8950, V5362, V5363, V5364 | |
Physician Services | PA Required | Integumentary Services | 11950, 11951, 11952, 11954, 15776, 17999, 96999, G0429 |
Injections | 64650, 64653, 90399, 0232T | ||
Other Services | 94774, 94777, 94799, 99199 | ||
PA required after 12 wound care visits | Wound Care | 11042, 11043, 11044 | |
No PA Required | Injections | 90281,90283 | |
Dialysis Services | 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970 | ||
Hearing Evaluations | 92626, 92627 | ||
Special Services | 19396, 92512, 92520, 92700 | ||
Home Visit | 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99374, 99375 | ||
Skin Procedures | PA Required | Cosmetic Procedures | 15780, 15781, 15782, 15783, 15786, 15788, 15789, 15792, 15793, 15819, 15824, 15825, 15826, 15828, 15829, 17340, 17360, 17380 |
Sleep Medicine | No PA Required | Sleep Studies | 95783, 95800, 95801, 95803, 95806, G0398, G0400 |
Stereotactic Radio Surgery | PA Required | Nervous System Procedures | 0398T |
No PA Required | Nervous System Procedures | 61796, 61797, 61798, 63620, 63621 | |
Surgery Procedures
Surgery Procedures
|
PA Required
PA Required | Integumentary Services | 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 0446T |
Lipectomy | 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879 | ||
Musculoskeletal Procedures | 20930, 20931, 20936, 20937, 20938, 21899, 23130, 23400, 23410, 23412, 23415, 23420, 23929, 24365, 27120, 27122, 27299, 27331, 27403, 27412, 27415, 27416, 27437, 27438, 27870, 29826, 29827, 29860, 29862, 29863, 29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29899, 29914, 29915, 29916, 29999, 0054T, 0055T, 0101T, G0259 | ||
Facial, Cranial & TMJ Procedures | 21089, 21120, 21121, 21122, 21123, 21125, 21137, 21138, 21139, 21151, 21155, 21208, 21209, 21210, 21215, 21230, 21235, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21270, 21296, 21299, 21499, 42145 | ||
Spinal Surgery | 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22224, 22226, 22510, 22511, 22512, 22513, 22514, 22515, 22526, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22857, 22858, 22859, 22861, 22864, 22865, 22867, 22868, 22869, 22870, 22899, 27279, 27280, 62287, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63045, 63046, 63047, 63048, 63050, 63051, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63172, 63185, 63190, 63190, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63306, 63307, 63308, 0200T, 0201T, 0219T, 0275T | ||
Chest, Abdomen, Pelvis Procedures | 22999, 39499, 49329, 49999, 0437T | ||
Joint Replacement Surgery | 23470, 23472, 23473, 23474, 24360, 24361, 24362, 24363, 24366, 24370, 24371, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 27125, 27130, 27132, 27134, 27137, 27138, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27702, 27703, 27704 | ||
Hemic & Lymphatic System Procedures | 38999 | ||
Endocrine System | 60699 | ||
Nervous System Procedures | 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64553, 64555, 64561, 64566, 64575, 64581, 64999, 0442T | ||
Eye & Ocular Adnexa Procedures | 66999, 67299, 67399, 67599, 67912, 67999, 68899, 0444T | ||
Auditory System Procedures | 69399, 69714, 69799 | ||
PA only required if billed with diagnosis of gender dysphoria | Integumentary Services | 11960, 11970, 14000, 14001, 15100, 15101, 15120, 15121, 15200, 15570, 15574, 15600, 15620, 15757, 15758, 15769, 15771, 15772, 15773, 15774 | |
Breast Services | 19303 | ||
Respiratory Services | 31599, 31899 | ||
PA not required if billed with breast cancer diagnosis | Breast Services | 19330, 19340, 19342, 19350, 19355, 19364, 19370, 19371, 19380, 19499 | |
No PA Required | Musculoskeletal Procedures | 21740, 21742, 21743 | |
Facial, Cranial & TMJ Procedures | 30460, 30462, 30630, 41530 | ||
Hernia Repair | 49650, 49651 | ||
Nervous System Procedures | 64595 | ||
Transplant Services | No PA Required | Transplant | 32855, 32856, 33406, 33410, 33411, 33412, 33413, 33930, 33933, 33940, 33944, 38204, 38205, 38206, 38207, 38208, 38210, 38212, 38213, 38214, 38215, 38230, 38232, 44715, 44720, 44721, 47133, 47140, 47142, 47143, 47144, 47145, 47146, 47147, 48550, 48551, 48552, 48556, 50323, 50325, 50327, 50328, 50329, 50547, S2055, S2140 |
Transportation Services | PA Required | Medical Transportation | S9960, S9961 |
No PA Required | Medical Transportation | A0021 |