Medicaid Prior Authorization Requirements for New 2025 Procedure Codes

Date: 12/16/25

Medicaid Prior Authorization Requirements for New 2025 Procedure Codes

Arizona Complete Health-Complete Care Plan requires prior authorization (PA) as a condition of payment for certain services. This communication outlines the PA requirements for new 2025 procedure codes. These requirements are effective for dates of service on or after October 1, 2025.

The table below includes the Medicaid PA requirement for the new codes. For the most accurate and up to date information, please use the Pre-Auth Check tool before delivering services: www.azcompletehealth.com → For Providers → Pre Auth Check. Please note: The Pre-Auth Check tool reflects PA requirements as of the time of your search. It does not show future updates or changes.

Please verify eligibility and benefits prior to rendering services for all 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 SERVICES EXCEPT WHERE SPECIFICALLY OTHERWISE INDICATED.

Questions? Contact your Provider Engagement Account Manager

Or email us at: AzCHProviderEngagement@azcompletehealth.com

Code	Description	PA Requirement Effective 10/1/2025
0580U	B BRGDRFERI ANTIBODY DETECTION 24 RPRTN GRPS IA	PA required for non-participating independent labs, for all other providers no PA required.
0581U	TRNSPLJ MED ANTB NONHLA BLD SPEC FCM SABT 39TRGT	PA required for non-participating independent labs, for all other providers no PA required.
0584U	NEURO CSF DETCJ PRION PRTN QUAKG CONF CONV QUAL	PA required for non-participating independent labs, for all other providers no PA required.
0587U	THER RX MNTR 60-150 RXANDMETABLTS UR SLV LC-MS/MS	PA required for non-participating independent labs, for all other providers no PA required.
0588U	NFCT DS BCT/VIRAL 32 GENES IMMUNE RESPONSE MRNA	PA required for non-participating independent labs, for all other providers no PA required.
0589U	PFAS 24 COMPOUNDS HI-PERF LC-MS/MS PLSM/SRM QUAN	PA required for non-participating independent labs, for all other providers no PA required.
0590U	NFCT DISEASE BCTANDFUNGAL DNA 44 ORGS URINE NGS	PA required for non-participating independent labs, for all other providers no PA required.
0593U	NFCT DS GU PTHGNS DNA 46 TRGTS RT-PCR AMP PRB TQ	PA required for non-participating independent labs, for all other providers no PA required.

Code	Description	PA Requirement Effective 10/1/2025
0594U	NFCT DS SEPSIS SEMIQ MEAS PNCRTC STN PRTN CONCTR	PA required for non-participating independent labs, for all other providers no PA required.
0595U	NFCT DS TFP VCTRBRNEANDZOONOTIC PTHGN 2VIR 1BCTRUM	PA required for non-participating independent labs, for all other providers no PA required.
A9612	INJECTION FLUORESCEIN 1 MG	No PA required for all providers.
A9616	GALLIUM GA-68 GOZETOTIDE GOZELLIX DIAG 1 MCI	No PA required for all providers.
J0458	INJ AZTREONAM/AVIBACTAM 7.5 MG/2.5 MG 10 MG	No PA required for all providers.
J0462	INJ ATROPINE SULF NOT THER EQ TO J0461 0.01 MG	No PA required for all providers.
J0525	INJECTION CEFOTETAN DISODIUM 10 MG	No PA required for all providers.
J0582	INJ BIVALIRUDIN ENDO NOT THER EQ TO J0583 1 MG	No PA required for all providers.
J0675	INJECTION CARBOPROST TROMETHAMINE 0.1 MG	No PA required for all providers.
J0759	INJECTION CLEVIDIPINE BUTYRATE 1 MG	No PA required for all providers.
J1370	INJECTION ESOMEPRAZOLE SODIUM 1 MG	No PA required for all providers.
J1612	INJECTION GLUCAGON GVOKE 0.01 MG	No PA required for all providers.
J1807	INJECTION ETHACRYNATE SODIUM 1 MG	No PA required for all providers.
J1834	INJECTION ISONIAZID 1 MG	No PA required for all providers.
J2151	INJECTION MANNITOL 250 MG	No PA required for all providers.
J2291	INJECTION NAFCILLIN SODIUM BAXTER 20 MG	No PA required for all providers.
J3290	INJECTION TRANEXAMIC ACID 5 MG	No PA required for all providers.
A4288	VALVE FOR BREAST PUMP REPLACEMENT	PA required for non-participating providers only.
C1740	LEADLESS ELECTRODE TX BATTERY SEQ LT VAT PACING	PA required for non-participating providers only.
C1741	ANCHOR/SCREW FOR BONE FIX ABSORBABLE IMPLANTABLE	PA required for non-participating providers only.

Code	Description	PA Requirement Effective 10/1/2025
C8006	INSERTION PLEURAL-PERITONEAL SHUNT W/INTCL PUMP	PA required for non-participating providers only.
E0150	COMBINATION WHL WALKER W/SEAT AND TRANSPORT CHAIR	PA required for non-participating providers only.
J0163	INJ EPINEPHRINE IN SODIUM CHLORIDE ENDO 0.1 MG	PA required for non-participating providers only.
J0164	INJ EPINEPHRINE IN SODIUM CHLORIDE BAXTER 0.1 MG	PA required for non-participating providers only.
J0681	INJECTION CEFTOBIPROLE MEDOCARIL SODIUM 3 MG	PA required for non-participating providers only.
M0235	IV INFUSION MONOCLONAL ANTIBODY PROD NOC 1ST DOS	PA required for non-participating providers only.
M0236	IV INFUSION MONOCLONAL ANTIBODY NOC 2ND DOS	PA required for non-participating providers only.
Q0235	INJECTION MONOCLONAL ANTIBODY NOC 1 MG	PA required for non-participating providers only.
0575U	TRNSPLJ MED LIVER ALGRFT REJ MIRNA RTPCR 4 GENES	PA required for all providers.
0576U	TRNSPLJ MED LVR ALGRFT REJ QUAN DDCFDNA WHLGENOM	PA required for all providers.
0577U	ONC OVARIAN SERUM ALYS 39 GPS LC-MS/MS MRM MODE	PA required for all providers.
0578U	ONC CUTAN MLNMA RNA GEN XPRSN RTQPCR 10GENS FFPE	PA required for all providers.
0579U	NFRO DBTC CKD ELISA APOA4 CD5L EGFR AGE PLSM ALG	PA required for all providers.
0582U	RARE DS RPD WHL GEN DNA SEQ SNVS INDELS VARIANTS	PA required for all providers.
0583U	RARE DS RPD WHL GEN CMPTR DNA SEQ VRNTS PROBAND	PA required for all providers.
0585U	TGSAP SO NEO CFDNA ALYS PLSM 521 GENES INTERROG	PA required for all providers.

Code	Description	PA Requirement Effective 10/1/2025
0586U	ONC MRNA GENE XPRSN PRFLG 216GENS RNA XPRSN ALYS	PA required for all providers.
0591U	ONC PRST8 CA BIOCHEM ALYS 3 PROTEIN PLASMA SERUM	PA required for all providers.
0592U	ONC HL NEOPLASM DNA TGS 417GENS INTERROG GEN FUS	PA required for all providers.
0596U	NEURO ALZ DS PLSM 3DSTNCT ISOFRM PEPTID LC-MS/MS	PA required for all providers.
0597U	ONC BRST RNA XPRSN PRFLG 329GENS TRGT NGS 20PRTN	PA required for all providers.
0598U	GI IBS IGG ANTBS 18 FOOD ITEMS MBIA WHL BLD/SRM	PA required for all providers.
0599U	ONC PANCREATIC CANCER MULTI IMMUNOASSAY SERUM	PA required for all providers.
A2036	COHEALYX COLLAGEN DERMAL MATRIX PER SQ CM	PA required for all providers.
A2037	G4DERM PLUS PER ML	PA required for all providers.
A2038	MARIGEN PACTO PER SQ CM	PA required for all providers.
A2039	INNOVAMATRIX FD PER SQ CM	PA required for all providers.
C1742	PRESSURE MONITORING SYSTEM IMPLANTABLE CNTNUS	PA required for all providers.
C9305	INJECTION NIPOCALIMAB-AAHU 3 MG	PA required for all providers.
C9306	INJECTION TELISOTUZUMAB VEDOTIN-TLLV 1 MG	PA required for all providers.
E0658	SEGMENTAL PNEUMATIC COMP 2 FULL ARMS AND CHEST	PA required for all providers.
E0659	SEG PNEU APPL USE W/PNEU COMP INTG HEAD NCK AND CT	PA required for all providers.
J0614	INJECTION TREOSULFAN 50 MG	PA required for all providers.
J0668	INSTILL BUPIVACAINE AND MELOXICAM 1 MG/0.03 MG	PA required for all providers.

Code	Description	PA Requirement Effective 10/1/2025
J0738	INJ LENACAPAVIR 1 MG RX ONLY FOR USE AS HIV PREP	PA required for all providers.
J0752	ORAL LENACAPAVIR 300 MG RX ONLY FOR USE HIV PREP	PA required for all providers.
J1809	INJECTION FOSDENOPTERIN 0.1 MG	PA required for all providers.
J3402	INJECTION REMESTEMCEL-L-RKND PER THER DOSE	PA required for all providers.
J3403	REVAKINAGENE TARORETCEL-LWEY PER IMPLANT	PA required for all providers.
J7173	INJECTION CONCIZUMAB-MTCI 0.5 MG	PA required for all providers.
J7174	INJECTION FITUSIRAN 0.04 MG	PA required for all providers.
J9011	INJECTION DATOPOTAMAB DERUXTECAN-DLNK 1 MG	PA required for all providers.
L1007	SCOLIOSIS ORTHOSIS SAGITTAL-CORONAL CTRL CUSTOM	PA required for all providers.
L5657	ADD LW EXT PROS MAN/AUTO LIMB VOL MGMT ANY MTRLS	PA required for all providers.
L6034	PAR HND FNGR AND THMB PROS NOT INCL INSR DESCR L6692	PA required for all providers.
L6035	SINGLE PROSTHETIC DIGIT MECH INITIAL ISSUE/REPLC	PA required for all providers.
L6036	PROSTHETIC THUMB MECH INITIAL ISSUE/REPLACEMENT	PA required for all providers.
L6038	ADD SINGLE PROS DIGIT/THUMB MECH ATT MULTIAXIAL	PA required for all providers.
L6039	PASSIVE PROSTHETIC DIGIT/THUMB PROS DIGIT/THUMB	PA required for all providers.
Q4383	AXOLOTL GRAFT ULTRA PER SQ CM	PA required for all providers.
Q4384	AXOLOTL DUALGRAFT ULTRA PER SQ CM	PA required for all providers.
Q4385	APOLLO FT PER SQ CM	PA required for all providers.
Q4386	ACESSO TRIFACA PER SQ CM	PA required for all providers.

Code	Description	PA Requirement Effective 10/1/2025
Q4387	NEOTHELIUM FT PER SQ CM	PA required for all providers.
Q4388	NEOTHELIUM 4L PER SQ CM	PA required for all providers.
Q4389	NEOTHELIUM 4L PLUS PER SQ CM	PA required for all providers.
Q4390	ASCENDION PER SQ CM	PA required for all providers.
Q4391	AMNIOPLAST DOUBLE PER SQ CM	PA required for all providers.
Q4392	GRAFIX DUO PER SQ CM	PA required for all providers.
Q4393	SURGRAFT AC PER SQ CM	PA required for all providers.
Q4394	SURGRAFT ACA PER SQ CM	PA required for all providers.
Q4395	ACELAGRAFT PER SQ CM	PA required for all providers.
Q4396	NATALIN PER SQ CM	PA required for all providers.
Q4397	SUMMIT AAA PER SQ CM	PA required for all providers.
Q5155	INJECT AFLIBERCEPT-JBVF YESAFILI BIOSIMILAR 1 MG	PA required for all providers.
Q5156	INJECT TOCILIZUMAB-ANOH AVTOZMA BIOSIMILAR 1 MG	PA required for all providers.
Q5157	INJECT DENOSUMAB-BMWO STOBOCLO/OSENVELT BS 1 MG	PA required for all providers.
Q5158	INJ DENOSUMAB-BNHT BOMYNTRA/CONEXXENCE BS 1 MG	PA required for all providers.
Q5159	INJECTION DENOSUMAB-DSSB OSPOMYV/XBRYK BS 1 MG	PA required for all providers.
H2018	PSYCHOSOCIAL REHABILITATION SERVICES, PER DIEM	PA required for all providers.
H2038	SKILLS TRAINING AND DEVELOPMENT PER DIEM	PA required for all providers.
Q5154	INJECTN OMALIZUMAB-IGEC OMLYCLO BIOSIMILAR 5 MG	Procedure code is not a covered benefit.