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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4 Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility) : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.19 Radiation Therapy Services : * Radiopharmaceuticals
Radiopharmaceuticals may be considered for separate reimbursement when used for therapeutic treatment.
The following procedure codes are payable to outpatient hospitals:
Procedure codes A9542, A9543, and A9545 require prior authorization. Tositumomab or Ibritumomab Tiuxetan will be considered when submitted with one of the following diagnosis codes:
Strontium-89 chloride may be billed using procedure code A9600 and will be limited to a total of 10 mci intravenously injected every 90 days, any provider.
Strontium-89 chloride is reimbursed as one service per day for the same provider on the same claim.
Strontium-89 chloride will be considered when submitted with diagnosis code C7951 or C7952.
Sodium phosphate p-32, therapeutic, will be considered when submitted with one of the following diagnoses:
Chromic phosphate p-32 suspension will considered when submitted with diagnosis code C782 (secondary malignant neoplasm of the pleura) and diagnosis code C786 (secondary malignant neoplasm of the retroperitoneum and peritoneum).
Refer to:
Subsection 9.2.60, “Radiation Therapy,” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Prior Authorization for Therapeutic Radiopharmaceuticals
Prior authorization is required for A9542, A9543, and A9545, which will be considered with documentation of all of the following:
Prior authorization must be requested through the SMPA department with appropriate documentation. Requests can be mailed or faxed to:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213
Requests for prior authorization can be submitted online through the TMHP website at

Texas Medicaid & Healthcare Partnership
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