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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:  

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, E0784, 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, E0260, 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