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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.42 Diagnostic and Therapeutic Breast Procedures : 9.2.42.4 Prior Authorization Requirements for Diagnostic and Therapeutic Breast Procedures

9.2.42.4
Prior authorization is not required for the following when all of the following criteria are met:
Prior authorization is required for the following:
9.2.42.4.1
All of the following documentation must be submitted for procedure code 19499 with the prior authorization request:
A Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code, which is comparable to the procedure being requested
9.2.42.4.2
In addition to documentation requirements outlined in the “Prior Authorization Requirements” section above, the following requirements apply:
All services are subject to retrospective review. Documentation in the client’s medical record must be maintained by the physician and must support the medical necessity for the services provided.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.