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36.6 Procedure Codes Requiring Prior Authorization
The following list is not all-inclusive and is subject to change:
Prior authorization is mandatory for these services (this list is noninclusive and subject to change):
• Abdominal lipectomies and panniculectomies.
•Baclofen and/or morphine pump implantation/revision/replacement.
Blepharochalasis/blepharoplasty/blepharoptosis repair (not required for procedure codes 2-67901, 2-67902, 2-67903, 2-67904, 2-67906, 2-67908, and 2-67909 for clients younger than 21 years of age with a diagnosis of 74361, 74362, or 7439). Procedure codes 2-67901, 2-67902, 2-67903, 2-67904, 2-67906, and 2-67908 do not require prior authorization for clients older than 21 years of age with diagnosis codes 37431, 37432, 37433, and 37434.
•Breast reduction.
•Communication devices (CCP only).
•Contact lenses (except postsurgical prosthetic contact lenses or emergency corneal bandage lenses or for the diagnosis of aphakia).
•Corneal topography performed by an optometrist.
•Corneal topography performed by an ophthalmologist.
•Customized DME (CCP only).
•Freestanding psychiatric facility (CCP only).
•Freestanding rehabilitation facility (CCP only).
•Heart transplants.
•Home delivery by a CNM.
•In-home respiratory services provided by a certified respiratory care practitioner.
•Kidney transplants.
•Liver transplants.
•Lung transplants.
•Maxillofacial/craniofacial surgery (excludes procedure code 2-61550 for cosurgery).
•Most home health services.
•Oral surgery-jaw deformities.
•Orthodontic services.
•Outpatient/in-home TPN/hyperalimentation.
•Outpatient mental health services in excess of 30-encounters per client per calendar year to enrolled practitioners.
•Private duty nursing (CCP only).
•Pancreas/simultaneous kidney-pancreas transplant.
•Stem cell transplants.
•Temporomandibular joint surgery.
•Treatment of life-threatening oral infections.
•Vagal nerve stimulator.
•Vestibuloplasty.
The following procedures do not require prior authorization:
•Cleft palate repair.
•Cochlear implantation.
•Contact lens(es) or replacement contact lens(es) for diagnosis of aphakia.
•Implant of a dorsal column spinal cord stimulator inserted to treat chronic intractable pain.
•Surgical removal of lesions, when medically necessary; use modifier KX, specific required documentation on file when excision/destruction is because of at least one of the following signs or symptoms: inflamed, growing, infected, bleeding, irritated, itching, limiting motion/function, or diagnosis 7020, actinic keratosis.
•Home Health Services/DME supplies for in-home use require prior authorization through Home Health Services.
Refer to: "THSteps-Comprehensive Care Program (CCP)"
"Corneal Topography" .
"Certified Respiratory Care Practitioner (CRCP) Services" .
"Texas Medicaid (Title XIX) Home Health Services" .
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