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Diagnosis Restriction for Afamelanotide Implant for Texas Medicaid

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures, such as prior authorization, precertification, referrals, and claims/encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client’s specific MCO for details.

Effective for dates of service on or after April 1, 2022, afamelanotide implant procedure code J7352 is a benefit of Texas Medicaid and is restricted to diagnosis code E800.

For more information, call the TMHP Contact Center at 800-925-9126.