Medicaid Prior Authorization Requirements for 2025 Procedure Codes

Date: 03/17/25

Medicaid Prior Authorization Requirements for New 2025 Procedure Codes

Arizona Complete Health-Complete Care Plan requires prior authorization (PA) for as a condition of payment for certain services. This communication outlines PA requirements for new 2025 procedure codes. The PA requirements are effective for dates of service 1/1/2025 and after.

NON-PARTICIPATING PROVIDERS & FACILITIES REQUIRE PA FOR ALL SERVICES UNLESS SPECIFICALLY OTHERWISE INDICATED.

Benefits are separate from PA requirements. If the service is a covered benefit, we then follow the PA requirements. In addition, payment, regardless of PA requirements, is contingent on the member’s eligibility at the time service is rendered. As a result, please verify eligibility and benefits prior to rendering services to members.

To confirm if a CPT/HCPCS code requires PA, please use the applicable Pre-Auth Check Tool on our website www.arizonacompletehealth.com > For Providers > Pre-Auth Check. Please Note: This tool displays the PA requirements at the time of the look-up. It does not display future changes to PA requirements.

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

Code	Description	PA Requirement Effective 1/1/2025
64466	THORACIC FASCIAL PLANE BLOCK UNI INJECTION	PA required for this service unless performed in an outpatient hospital setting on the same date as surgery.
64467	THORACIC FASCIAL PLANE BLOCK UNI CONT INFUSION	PA required for this service unless performed in an outpatient hospital setting on the same date as surgery.
64468	THORACIC FASCIAL PLANE BLOCK BI INJECTION	PA required for this service unless performed in an outpatient hospital setting on the same date as surgery.
64469	THORACIC FASCIAL PLANE BLOCK BI CONT INFUSION	PA required for this service unless performed in an outpatient hospital setting on the same date as surgery.
64473	LOWER XTR FASCIAL PLANE BLOCK UNI INJECTION	PA required for this service unless performed in an outpatient hospital setting on the same date as surgery.
64474	LOWER XTR FASCIAL PLANE BLOCK UNI CONT INFUSION	PA required for this service unless performed in an outpatient hospital setting on the same date as surgery.
C1735	CATHETER INTRAVASCULAR FOR RENAL DNV RADIOFREQ	PA required for All providers.
Code	Description	PA Requirement Effective 1/1/2025
C1736	CATHETER INTRAVASCULA FOR RENAL DENERVATION U/S	PA required for All providers.
C1737	JOINT FUSION AND FIXN DEVICE SACROILIAC AND PELVIS	PA required for All providers.
C8002	PREPARATION SKIN CELL SUSP AUTOGRAFT AUTOMATED	PA required for All providers.
C8003	IMPLANT MEDIAL KNEE EXTRAART IMPLANT SHOCK ABS	PA required for All providers.
C9173	INJECTION FILGRASTIM-TXID NYPOZI BIOSIMILR 1 MCG	PA required for All providers.
E1803	DYNAMIC ADJUSTABLE ELBOW EXTENSION ONLY DEVICE	PA required for All providers.
E1804	DYNAMIC ADJUSTABLE ELBOW FLEXION ONLY DEVICE	PA required for All providers.
E1807	DYNAMIC ADJUSTABLE WRIST EXTENSION ONLY DEVICE	PA required for All providers.
E1808	DYNAMIC ADJUSTABLE WRIST FLEXION ONLY DEVICE	PA required for All providers.
E1813	DYNAMIC ADJUSTABLE KNEE EXTENSION ONLY DEVICE	PA required for All providers.
E1814	DYNAMIC ADJUSTABLE KNEE FLEXION ONLY DEVICE	PA required for All providers.
E1822	DYNAMIC ADJUSTABLE ANKLE EXTENSION ONLY DEVICE	PA required for All providers.
E1823	DYNAMIC ADJUSTABLE ANKLE FLEXION ONLY DEVICE	PA required for All providers.
E1826	DYNAMIC ADJUSTABLE FINGER EXTENSION ONLY DEVICE	PA required for All providers.
E1827	DYNAMIC ADJUSTABLE FINGER FLEXION ONLY DEVICE	PA required for All providers.
E1828	DYNAMIC ADJUSTABLE TOE EXTENSION ONLY DEVICE	PA required for All providers.
E1829	DYNAMIC ADJUSTABLE TOE FLEXION ONLY DEVICE	PA required for All providers.

Code	Description	PA Requirement Effective 1/1/2025
G0552	SUPPLY DGTL MENTAL HEALTH TX DVC PER CRS OF TX	PA required for All providers.
G0563	SBRT TX DEL POSITRON EMISSION-BASED DELIVERY	PA required for All providers.
G0564	CREATION SUBC PKT INS 365 DAY IMPLANT GLUC SNSR	PA required for All providers.
J0139	INJECTION ADALIMUMAB 1 MG	PA required for All providers.
J0601	SEVELAMER CARBONATE ORAL 20 MG	PA required for All providers.
J0602	SEVELAMER CARBONATE ORAL POWDER 20 MG	PA required for All providers.
J0603	SEVELAMER HYDROCHLORIDE ORAL 20 MG	PA required for All providers.
J0605	SUCROFERRIC OXYHYDROXIDE ORAL 5 MG	PA required for All providers.
J0607	LANTHANUM CARBONATE ORAL 5 MG	PA required for All providers.
J0608	LANTHANUM CARBONATE PWD 5 MG NOT EQUIV TO J0607	PA required for All providers.
J0609	FERRIC CITRATE ORAL 3 MG FERRIC IRON	PA required for All providers.
J0870	INJECTION IMETELSTAT 1 MG	PA required for All providers.
J0901	VADADUSTAT ORAL 1 MG	PA required for All providers.
J1307	INJECTION CROVALIMAB-AKKZ 10 MG	PA required for All providers.
J1414	INJECTION FIDANACOGENE ELAPARVOVEC-DZKT PER TX D	PA required for All providers.
J1552	INJECTION IMMUNE GLOBULIN ALYGLO 500 MG	PA required for All providers.
J2802	INJECTION ROMIPLOSTIM 1 MCG	PA required for All providers.
J3392	INJECTION EXAGAMGLOGENE AUTOTEMCEL PER TREATMENT	PA required for All providers.
J7514	MYCOPHENOLATE MOFETIL MYHIBBIN ORAL SUSP 100 MG	PA required for All providers.
J7601	ENSIFENTRINE INH SUSP FDA-APPD PROD NONCMPD 3 MG	PA required for All providers.

Code	Description	PA Requirement Effective 1/1/2025
J9026	INJECTION TARLATAMAB-DLLE 1 MG	PA required for All providers.
J9028	INJ NOGAPENDEKIN ALFA INBAKICEPT-PMLN IVES 1 MCG	PA required for All providers.
J9076	INJECTION CYCLOPHOSPHAMIDE BAXTER 5 MG	PA required for All providers.
J9292	INJECTN PEM AVYXA NOT THER EQUIV TO J9305 10 MG	PA required for All providers.
Q0155	DRO SYNDROS 0.1 MG ORAL FDA-APRVD RX ANTI-EMETIC	PA required for All providers.
Q4346	SHELTER DM MATRIX PER SQ CM	PA required for All providers.
Q4347	RAMPART DL MATRIX PER SQ CM	PA required for All providers.
Q4348	SENTRY SL MATRIX PER SQ CM	PA required for All providers.
Q4349	MANTLE DL MATRIX PER SQ CM	PA required for All providers.
Q4350	PALISADE DM MATRIX PER SQ CM	PA required for All providers.
Q4351	ENCLOSE TL MATRIX PER SQ CM	PA required for All providers.
Q4352	OVERLAY SL MATRIX PER SQ CM	PA required for All providers.
Q4353	XCEED TL MATRIX PER SQ CM	PA required for All providers.
Q5139	INJECTION ECULIZUMAB-AEEB BKEMV BIOSIMILAR 10 MG	PA required for All providers.
Q5140	INJECTION ADALIMUMAB-FKJP BIOSIMILAR 1 MG	PA required for All providers.
Q5141	INJECTION ADALIMUMAB-AATY BIOSIMILAR 1 MG	PA required for All providers.
Q5142	INJECTION ADALIMUMAB-RYVK BIOSIMILAR 1 MG	PA required for All providers.
Q5143	INJECTION ADALIMUMAB-ADBM BIOSIMILAR 1 MG	PA required for All providers.
Q5144	INJECTION ADALIMUMAB-AACF IDACIO BIOSIMILAR 1 MG	PA required for All providers.
Q5145	INJECTION ADALIMUMAB-AFZB ABRILADA BS 1 MG	PA required for All providers.

Code	Description	PA Requirement Effective 1/1/2025
Q5146	INJECTION TRASTUZUMAB-STRF HERCESSI BS 10 MG	PA required for All providers.
Q9996	INJECTION USTEKINUMAB-TTWE PYZCHIVA SC 1 MG	PA required for All providers.
Q9997	INJECTION USTEKINUMAB-TTWE PYZCHIVA IV 1 MG	PA required for All providers.
Q9998	INJECTION USTEKINUMAB-AEKN SELARSDI 1 MG	PA required for All providers.
0523U	ONC SOLID TUMOR DNA QUAL NGS SNV 22GEN FFPE TISS	PA required for All providers.
0529U	HEM VTE GW SNP F2 AND F5 GENE ALYS AND LEIDEN VRNT SLV	PA required for All providers.
0530U	ONC PAN-SOL TUM CTDNA PLSM NGS 77 GEN 8 FUJN MSI	PA required for All providers.
0901T	PLACEMENT BONE MARROW SAMPLING PORT W/IMG GDN	PA required for All providers.
0906T	COMS THERAPY WND ASSMT AND DR 1ST APPL <=50 SQ CM	PA required for All providers.
0907T	COMS THERAPY WND ASSMT AND DR EA ADDL APPL<=50 SQ CM	PA required for All providers.
0908T	OPEN IMPLTJ INT NEUROSTIMULATION SYS VAGUS NERVE	PA required for All providers.
0909T	REPLACEMENT INT NEUROSTIMULATION SYS VAGUS NERVE	PA required for All providers.
0910T	REMOVAL INT NEUROSTIMULATION SYS VAGUS NERVE	PA required for All providers.
0913T	PERQ TCAT THER RX DLVR NTRAC RX BALO 1 MAJ C ART	PA required for All providers.
0914T	PERQ TCAT THER RX DLVR NTRAC RX BALO SEPARATE	PA required for All providers.
0915T	INSJ PERM CCM-D SYS PG AND DUAL TRANSVNS ELTRDS/LDS	PA required for All providers.
0916T	INSERTION PERM CCM-D SYSTEM PULSE GENERATOR ONLY	PA required for All providers.

Code	Description	PA Requirement Effective 1/1/2025
0917T	INSJ PERM CCM-D SYS 1 TRANSVNS LEAD ONLY	PA required for All providers.
0918T	INSJ PERM CCM-D SYS DUAL TRANSVNS LEADS ONLY	PA required for All providers.
0919T	REMOVAL PERM CCM-D SYSTEM PULSE GENERATOR ONLY	PA required for All providers.
0920T	RMVL PERM CCM-D SYS 1 TRANSVNS PACING LEAD ONLY	PA required for All providers.
0921T	RMVL PERM CCM-D SYS 1 TRANSVNS DFB LEAD ONLY	PA required for All providers.
0922T	RMVL PERM CCM-D SYS DUAL TRANSVNS LEADS ONLY	PA required for All providers.
0923T	RMVL AND RPLCMT PERMANENT CCM-D PULSE GENERATOR ONLY	PA required for All providers.
0924T	REPOSITIONING PREV IMPL CCM-D TRANSVNS ELTRD/LD	PA required for All providers.
0925T	RELOCATION SKIN POCKET IMPLANTED CCM-D PG	PA required for All providers.
0933T	TCAT IMPLT WRLS L ATR PRS SNR L-T L ATR PRS MNTR	PA required for All providers.
0935T	CYSTO W/RNL PEL SYMPATHETIC DNRVTJ RF ABLTJ BI	PA required for All providers.
0941T	CYSTO FLX INSJ AND XPNSJ PROSTATIC URTL SCAFFOLD	PA required for All providers.
0942T	CYSTO FLX RMVL AND RPLCMT PROSTATIC URTL SCAFFOLD	PA required for All providers.
0943T	CYSTO FLX REMOVAL PROSTATIC URETHRAL SCAFFOLD	PA required for All providers.
0944T	3D CONTOUR SIMULAJ TRGT LVR LES AND MRGN MICRWV ABLT	PA required for All providers.
0945T	INTRAOP ASMT ABNL TUM TIS IN-VIVO FLWG PRTL MAST	PA required for All providers.
0946T	ORTHOPEDIC IMPLT MVMT ALYS PAIRED CT TRGT STRUX	PA required for All providers.

Code	Description	PA Requirement Effective 1/1/2025
0947T	MRGFUS STRTCTC BLD-BRN BARR DISRPJ MBUBB RSN8TR	PA required for All providers.
81195	CYTOG GEN-WIDE ALYS HEM MAL STRUX VRNT AND CNV OGM	PA required for All providers.
81558	TRNSPLJ REJ KDN MRNA GENE XPRSN PRFLG QPCR 139	PA required for All providers.