CurrentArizona Complete HealthPolicy N/A

AZ Complete Health CMS Final Rule 0057-F Prior Authorization Requirements: 102 (PDF)

This part lists procedure and service groupings with associated CPT/HCPCS/T-Codes that may require prior authorization under Arizona Complete Health. It notes the ordering/prescribing provider is responsible for determining which specific codes require prior authorization.

Policy Summary

PayerArizona Complete Health

PolicyAZ Complete Health CMS Final Rule 0057-F Prior Authorization Requirements: 102 (PDF)

Policy CodePolicy N/A

Change TypeListing / prior authorization requirements (Part 2)

Effective Date12/31/2025

Next Review DateN/A

Key ActionOrdering/prescribing providers must determine which specific procedure codes require prior authorization; failure to obtain required prior authorization may result in claim denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported in this Part 2 listing.

~300Procedure codes listed in Part 2

Policy summary & scope

This document is Part 2 of a multi-part prior authorization requirements list from Arizona Complete Health (CMS Final Rule 0057-F). It enumerates procedure and service groupings with associated CPT/HCPCS/T-Codes that may require prior authorization, including services across surgical specialties, major joint reconstruction and arthroscopy, spine surgery, therapy (PT/OT/Speech and chiropractic), respiratory diagnostics, hearing services and devices, telehealth, therapeutic injections and vaccines/immune globulin, transportation, and urological/kidney procedures.

Prior authorization applicability & provider responsibilities

Provider Responsibility Statement

Operational responsibility for identifying PA-required codes:

Provider Responsibility: It is the ordering/prescribing provider's responsibility to determine which specific codes require prior authorization.

Verify eligibility and benefits prior to rendering services; see Online Prior Authorization Tool for complete code listing.

Service / Procedure Code Groupings

Listed procedure codes are grouped by service; presence in the list indicates potential prior authorization requirement:

Orthopedic & Spine Surgery: Procedure Codes = 0055T, 0707T, 0869T, 0946T, 20560, 20561, 20930, 20931, 20936, 20937, 20938, 20939, 21012, 21013, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21150, 21151, 21155, 21160, 21184, 21208, 21209, 21210, 21215, 21230, 21235, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21260, 21261, 21268, 21270, 21280, 21282, 21295, 21296, 21299, 21320, 21336, 21499, 21552, 21554, 21555, 21556, 21899, 21930, 21931, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22856, 22857

Major Joint Reconstruction & Arthroscopy (group 1): Procedure Codes = 22858, 22859, 22860, 22861, 22862, 22864, 22865, 22867, 22868, 22869, 22870, 22899, 22902, 22903, 22999, 23071, 23075, 23130, 23333, 23334, 23335, 23616, 23800, 23802, 23929, 24071, 24160, 24164, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 25800, 25805, 25810, 25820, 25825, 27033, 27090, 27091, 27096, 27120, 27122, 27125, 27236, 27278, 27279, 27280, 27299, 27327, 27337, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429, 27437, 27438, 27488, 27632, 27700, 27702, 27703, 27704, 27870

Major Joint Reconstruction & Arthroscopy (group 2): Procedure Codes = 23400, 23410, 23412, 23415, 23420, 23470, 23472, 23473, 23474, 27130, 27132, 27134, 27137, 27138, 27331, 27332, 27333, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29826, 29827, 29835, 29840, 29845, 29846, 29848, 29850, 29851, 29855, 29856, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29893, 29899

Spine Surgery (Fusion, Laminectomy, & Deformity): Procedure Codes = 29914, 29915, 29916, 29999, C8003, G0289, 0095T, 0098T, 0164T, 0165T, 0656T, 0657T, 0790T, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22836, 22837, 22838, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, C9757, G0276, G0277

Physical, Occupational, and Speech Therapy - Chiropractic Services: Procedure Codes = 98941, 98943

Physical, Occupational, and Speech Therapy - PT/OT/Speech therapy: Procedure Codes = 0693T, 0791T, 97124, 97129, 97130

Physical, Occupational, and Speech Therapy - Therapy Modalities (Ultrasound, Traction, Stim): Procedure Codes = 0794T, 97033, 97039, 97799

Plastic & Reconstructive - Cosmetic & Functional Reconstructive Surgery: Procedure Codes = 15788, 15789, 15792, 15793, 15830, 15847

Plastic - Rhinoplasty: Procedure Codes = 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468

Respiratory Services - Pulmonary Function Tests & Diagnostics: Procedure Codes = 94799

Speech, Language, and Hearing - Hearing and Speech Evaluations: Procedure Codes = 92615

Speech, Language, and Hearing - Hearing devices and audiology supplies: Procedure Codes = V5030, V5040, V5050, V5060, V5070, V5080, V5095, V5100, V5120, V5130, V5140, V5221, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5275, V5298, V5299, V5336

Telehealth Services: Procedure Codes = 0650T, S9110

Therapeutic Injections & Infusions - Injections: muscles, tendons, bursa, joints, soft tissue: Procedure Codes = 11960, 11970, 20553

Therapeutic Injections & Infusions - Vaccine and Immune Globulin: Procedure Codes = 90378, 90380, 90381, 90678

Transportation Services: Procedure Codes = A0428, A0430, A0431, A0435, A0436, A0999

Urological & Kidney Surgery - Diagnostic procedures, male genital (includes minor surgery): Procedure Codes = 0864T, 54125, 54520, 54660, 54690, 54699, 54840, 55040, 55175, 55180, 55700, 55899

Urological & Kidney Surgery - Kidney transplant: Procedure Codes = 50300, 50320, 50340, 50360, 50365, 50370, 50380

Urological & Kidney Surgery - Nephrectomy and Major Urinary Tract Reconstruction: Procedure Codes = 0632T, 0672T, 0888T, 0935T, 50549, 51999, 53410, 53415, 53420, 53425, 53430, 53460, 54360, 54406, 54408, 54410, 54411, 54415, 54416, 54420

Urological & Kidney Surgery - Open prostatectomy: Procedure Codes = 55866, 55870

Urological & Kidney Surgery - Other diagnostic procedures of urinary tract: Procedure Codes = 0872T, 50590, 52000, 52005, 52204, 52224, 52234, 52235, 52260, 52276, 52281, 52287, 52310, 52320, 52332, 52344, 52351, 52352, 52353, 52356, 53899

Urological & Kidney Surgery - Transurethral resection of prostate (TURP): Procedure Codes = 0655T, 0867T, 0941T, 0942T, 0943T, 0950T, 53854

Documentation Required

Provider responsibility to identify PA-required codes

Ordering/prescribing providers must determine which specific procedure codes require prior authorization; the lists are illustrative groupings. Failure to obtain required prior authorization may result in claim denial.

Ordering/prescribing provider is responsible for identifying PA-required codes.
The procedure code groupings in the document are illustrative; verify specific codes via the online prior authorization tool or payer guidance.
Failure to obtain required prior authorization may result in claim denial.

Procedure codes (grouped)

Procedure codes potentially requiring prior authorization (listed by service groups in document)mixed

0055T
0707T
0869T
0946T
20560
20561
20930
20931
20936
20937

1–10 of 537

1/54

Orthopedic & Spine Surgerymixed

No codes listed

Major Joint Reconstruction & Arthroscopy (group 1)mixed

No codes listed

Major Joint Reconstruction & Arthroscopy (group 2)mixed

No codes listed

Spine Surgery (Fusion, Laminectomy, & Deformity)mixed

No codes listed

Physical, Occupational, and Speech Therapy - Chiropractic Servicesmixed

No codes listed

Physical, Occupational, and Speech Therapy - PT/OT/Speech therapymixed

No codes listed

Physical, Occupational, and Speech Therapy - Therapy Modalities (Ultrasound, Traction, Stim)mixed

No codes listed

Plastic & Reconstructive - Cosmetic & Functional Reconstructive Surgerymixed

No codes listed

Plastic - Rhinoplastymixed

No codes listed

Respiratory Services - Pulmonary Function Tests & Diagnosticsmixed

No codes listed

Speech, Language, and Hearing - Hearing and Speech Evaluationsmixed

No codes listed

Speech, Language, and Hearing - Hearing devices and audiology suppliesmixed

No codes listed

Telehealth Servicesmixed

No codes listed

Therapeutic Injections & Infusions - Injections: muscles, tendons, bursa, joints, soft tissuemixed

No codes listed

Therapeutic Injections & Infusions - Vaccine and Immune Globulinmixed

No codes listed

Transportation Servicesmixed

No codes listed

Urological & Kidney Surgery - Diagnostic procedures, male genital (includes minor surgery)mixed

No codes listed

Urological & Kidney Surgery - Kidney transplantmixed

No codes listed

Urological & Kidney Surgery - Nephrectomy and Major Urinary Tract Reconstructionmixed

No codes listed

Urological & Kidney Surgery - Open prostatectomymixed

No codes listed

Urological & Kidney Surgery - Other diagnostic procedures of urinary tractmixed

No codes listed

Urological & Kidney Surgery - Transurethral resection of prostate (TURP)mixed

No codes listed

OpenPayer

AZ Complete Health CMS Final Rule 0057-F Prior Authorization Requirements: 102 (PDF)

Policy summary & scope

Prior authorization applicability & provider responsibilities

Procedure codes (grouped)

What providers must do

Definitions & terms

Document changes