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Revision Ambetter Prior Authorization List Effective 7.1.2023

Date: 06/22/23

Ambetter Prior Authorization Change Effective 7/1/2023-UPDATE!

Ambetter from Arizona Complete Health requires prior authorization (PA) as a condition of payment for designated services.  It is the ordering/prescribing/referring provider’s responsibility to determine which specific codes require PA.

Please verify eligibility and benefits prior to rendering services for members. Payment, regardless of PA, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE PA FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.       

To confirm if a CPT/HCPCS code requires PA, please use the Ambetter Pre-Auth Check Tool on the Arizona Complete Health Website  > For Providers > Pre-Auth Check

UPDATE: Physical Medicine and Rehabilitation Codes 97010, 97012, 97014, 97032, 97035, 97110, 97112, 97116, 97140, 97530, and 97533 that were included in the table below on page 3 are being removed and will Not require prior auth effective 7/1/23.

The table below outlines changes effective 7/1/2023:

Service Category

PA Rule


Procedure Codes


No PA Required for Par providers

Dispensing fees

V5110, V5160, V5200, V5240, V5241

Hearing aid, molds, battery

V5264, V5265, V5266, V5267, V5275

Hearing aid repair/modification

V5014, V5336

Behavioral Health

PA Required

Alcohol and/or drug services


Mental health services


No PA Required for Par providers

Alcohol and/or drug services

H0005, H0014

Breast reconstruction

PA Required except with breast cancer diagnosis

Breast reconstruction, prosthesis

19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8031


PA Required


37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231

External counterpulsation


No PA Required for Par providers

Lead, pacemaker/cardioverter-defibrillator combination



DME & Supplies

PA Required

Compression burn garment

A6501, A6507, A6511

Miscellaneous DME supply


Respiratory assist device


Osteogenesis stimulator


Wheelchair accessories

E2620, E2622, E2624 

Personal care item


Supplies for home delivery


No PA Required for Par providers

Respiratory equipment


Infusion pumps and supplies

B9002, E0781



Evaluation & Management

PA Required

Office visit for provision of esketamine


Home Health Services

PA Required (Except for Professional Cares (PHCN))

Home health skilled nursing visit

Revenue Code 551

Home Care Management Services


Home therapy

G2168, G2169

Unskilled respite care

S5150, S5151

Nursing assessment/evaluation

T1001, T1028

No PA Required for Par providers

Home dialysis (ESRD)

90966, S9335, S9339

Prenatal home visit


Post-discharge home care and care plan oversight

G2001, G2002, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015

BPCI home visit


Remote in-home visits

G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987

Practitioner home visit

S0270, S0271, S0272, S0273, S0274

Medical home program

S0280, S0281

Home visit, wound care

S9097, S9098

Home infusion therapy

Q2052, S5035, S5036, S9347

Home care training

S5108, S5109, S5110, S5111, S5115, S5116


PA Required

Genetic analysis/studies, surgical pathology procedures

81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 0089U

No PA Required for Par providers

Blood and blood products

P9010, P9011, P9016, P9021, P9022, P9051, P9054, P9056, P9057, P9058


PA Required

Medical food nutritionally complete (oral)



PA Required

Procedures lower extremities

28285, 28299

Endoscopy wrist




PA Required

Dynamic adjustable forearm device


Knee orthosis (ko)

L1851, L1852

No PA Required for Par providers

Ankle foot orthosis (AFO)



PA Required

Tonsillectomy & adenoidectomy

42820, 42821, 42825, 42826, 42830, 42831

Pain management

PA Required unless performed on the same day as surgery

Injection, anesthetic agent or steroid

62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520, 64530

No PA Required for Par providers

Transversus abdominis plane (TAP) block

64486, 64488

Nerve block



No PA Required for Par providers

Developmental and behavioral screening

96110, 96112

Professional services

No PA Required for Par providers

Medication administration

G0068, G0069, G0070

Services performed in the hospice setting

G9473, G9474, G9475, G9476, G9477, G9478, G9479

Admission to Medicare care choice model program (MCCM)


Radiology Treatments

PA Required

Radiation therapy services

77372, 77373, G0339, G0340

Indium in-111 ibritumomab, dx


Ablation of prostate, liver tumor

47382, 0421T

Skin substitute

PA Required

Skin substitute products

Q4111, Q4114, Q4130, Q4137, Q4139, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226


PA Required

Procedures performed on Cornea


If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us: