Provider Alert! Prior Authorization Requirements Guide
Attention: All Providers
Effective Date: March 8, 2021
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Texas Children’s Health Plan (TCHP) would like to inform network providers of services that require a prior authorization effective March 8, 2021.Below are the services by category to include the HCPCS Code description.
| Controlled Dose Inhalation Drug Delivery Systems Require PA | ||
| K0730 | Controlled dose inhalation drug delivery system | 3/8/2021 |
| Secretion and Mucous Clearance Devices Require PA | ||
| E0500 | IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source | 3/8/2021 |
| Cosmetic Services Require PA | ||
| 15786 | Abrasion; single lesion (eg, keratosis, scar) | 3/8/2021 |
| 15787 | Abrasion; each additional 4 lesions or less (List separately | 3/8/2021 |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy | 3/8/2021 |
| Cosmetic Services Require PA for Ages 21 and Older | ||
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) | 3/8/2021 |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) | 3/8/2021 |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach | 3/8/2021 |
| 67909 | Reduction of overcorrection of ptosis | 3/8/2021 |
| 67911 | Correction of lid retraction | 3/8/2021 |
| Single-photon Emission Computerized Tomography (SPECT) Scans No Longer Require PA | ||
| 78071 | Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) | |
| 78072 | Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization | |
| Auditory Function Evaluation listed incorrectly under Speech Therapy No Longer Require PA | ||
| 92620 | Evaluation of central auditory function, with report; initial 60 minutes | |
| Therapeutic and Reconstructive Breast Procedures Require PA | ||
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less | 3/8/2021 |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm | 3/8/2021 |
| 11922 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof | 3/8/2021 |
| 19300 | Mastectomy for gynecomastia | 3/8/2021 |
| 19328 | Removal of intact mammary implan | 3/8/2021 |
| 19330 | Removal of mammary implant material | 3/8/2021 |
| 19396 | Preparation of moulage for custom breast implant | 3/8/2021 |
| Biofeedback Require PA | ||
| 90901 | Biofeedback training by any modality | 3/8/2021 |
| 90912 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient | 3/8/2021 |
| 90913 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure) | 3/8/2021 |
| Orthotic Codes Require PA | ||
| L0112 | Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated | 3/8/2021 |
| L0220 | Thoracic, rib belt, custom fabricated | 3/8/2021 |
| L0460 | Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0466 | Thoracic-lumbar-sacral orthosis (TLSO), sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0480 | Thoracic-lumbar-sacral orthosis (TLSO), triplanar control, one-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated | 3/8/2021 |
| L0622 | Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated | 3/8/2021 |
| L0624 | Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated | 3/8/2021 |
| L0626 | Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0627 | Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0629 | Lumbar-sacral orthosis (LSO), flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated | 3/8/2021 |
| L0631 | Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0632 | Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated | 3/8/2021 |
| L0633 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0634 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated | 3/8/2021 |
| L0636 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated | 3/8/2021 |
| L0637 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0639 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L0640 | Lumbar-sacral orthosis (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated | 3/8/2021 |
| L1610 | Hip orthosis (HO), abduction control of hip joints, flexible, (Frejka cover only), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L1620 | Hip orthosis (HO), abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L1630 | Hip orthosis (HO), abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated | 3/8/2021 |
| L1640 | Hip orthosis (HO), abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated | 3/8/2021 |
| L1680 | Hip orthosis (HO), abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated | 3/8/2021 |
| L1685 | Hip orthosis (HO), abduction control of hip joint, postoperative hip abduction type, custom fabricated | 3/8/2021 |
| L1700 | Legg Perthes orthosis, (Toronto type), custom fabricated | 3/8/2021 |
| L1710 | Legg Perthes orthosis, (Newington type), custom fabricated | 3/8/2021 |
| L1720 | Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated | 3/8/2021 |
| L1730 | Legg Perthes orthosis, (Scottish Rite type), custom fabricated | 3/8/2021 |
| L1755 | Legg Perthes orthosis, (Patten bottom type), custom fabricated | 3/8/2021 |
| L1810 | Knee orthosis (KO), elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L1834 | Knee orthosis (KO), without knee joint, rigid, custom fabricated | 3/8/2021 |
| L1840 | Knee orthosis (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated | 3/8/2021 |
| L1843 | Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L1844 | Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | 3/8/2021 |
| L1846 | Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated | 3/8/2021 |
| L1847 | Knee orthosis (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L1860 | Knee orthosis (KO), modification of supracondylar prosthetic socket, custom fabricated (SK) | 3/8/2021 |
| L1900 | Ankle-foot orthosis (AFO), spring wire, dorsiflexion assist calf band, custom fabricated | 3/8/2021 |
| L1904 | Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, custom fabricated | 3/8/2021 |
| L1920 | Ankle-foot orthosis (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated | 3/8/2021 |
| L1980 | Ankle-foot orthosis (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar ‘BK’ orthosis), custom fabricated | 3/8/2021 |
| L1990 | Ankle-foot orthosis (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar ‘BK’ orthosis), custom fabricated | 3/8/2021 |
| L2000 | Knee-ankle-foot orthosis (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthosis), custom fabricated | 3/8/2021 |
| L2005 | Knee-ankle-foot orthosis (KAFO), any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated | 3/8/2021 |
| L2006 | Knee-ankle-foot (KAF) device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated | 3/8/2021 |
| L2010 | Knee-ankle-foot orthosis (KAFO), single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthosis), without knee joint, custom fabricated | 3/8/2021 |
| L2020 | Knee-ankle-foot orthosis (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar ‘AK’ orthosis), custom fabricated | 3/8/2021 |
| L2030 | Knee-ankle-foot orthosis (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar ‘AK’ orthosis), without knee joint, custom fabricated | 3/8/2021 |
| L2034 | Knee-ankle-foot orthosis (KAFO), full plastic, single upright, with or without free motion knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated | 3/8/2021 |
| L2038 | Knee-ankle-foot orthosis (KAFO), full plastic, with or without free motion knee, multi-axis ankle, custom fabricated | 3/8/2021 |
| L2050 | Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated | 3/8/2021 |
| L2060 | Hip-knee-ankle-foot orthosis (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated | 3/8/2021 |
| L2070 | Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated | 3/8/2021 |
| L2080 | Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated | 3/8/2021 |
| L2090 | Hip-knee-ankle-foot orthosis (HKAFO), torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/ belt, custom fabricated | 3/8/2021 |
| L2106 | Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated | 3/8/2021 |
| L2108 | Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, custom fabricated | 3/8/2021 |
| L2126 | Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated | 3/8/2021 |
| L2128 | Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, custom fabricated | 3/8/2021 |
| L2232 | Addition to lower extremity orthosisis, rocker bottom for total contact ankle-foot orthos (AFO), for custom fabricated orthosis only | 3/8/2021 |
| L2320 | Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis only | 3/8/2021 |
| L2330 | Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only | 3/8/2021 |
| L2520 | Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted | 3/8/2021 |
| L2526 | Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted | 3/8/2021 |
| L2800 | Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only | 3/8/2021 |
| L3230 | Orthopedic footwear, custom shoe, depth inlay, each | 3/8/2021 |
| L3250 | Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each | 3/8/2021 |
| L3252 | Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each | 3/8/2021 |
| L3253 | Foot, molded shoe, Plastazote (or similar), custom fitted, each | 3/8/2021 |
| L3671 | Shoulder orthosis (SO), shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3674 | Shoulder orthosis (SO), abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3677 | Shoulder orthosis (SO), shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L3702 | Elbow orthosis (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3720 | Elbow orthosis (EO), double upright with forearm/arm cuffs, free motion, custom fabricated | 3/8/2021 |
| L3730 | Elbow orthosis (EO), double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated | 3/8/2021 |
| L3740 | Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated | 3/8/2021 |
| L3763 | Elbow-wrist-hand orthosis (EWHO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3764 | Elbow-wrist-hand orthosis (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3765 | Elbow-wrist-hand-finger orthosis (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3766 | Elbow-wrist-hand-finger orthosis (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3806 | Wrist-hand-finger orthosis (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3891 | Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each | 3/8/2021 |
| L3900 | Wrist-hand-finger orthosis (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated | 3/8/2021 |
| L3901 | Wrist-hand-finger orthosis (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom fabricated | 3/8/2021 |
| L3904 | Wrist-hand-finger orthosis (WHFO), external powered, electric, custom fabricated | 3/8/2021 |
| L3915 | Wrist-hand orthosis (WHO), includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L3917 | Hand orthosis (HO), metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L3921 | Hand-finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3923 | Hand-finger orthosis (HFO), without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L3929 | Hand-finger orthosis (HFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with exp | 3/8/2021 |
| L3933 | Finger orthosis (FO), without joints, may include soft interface, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3935 | Finger orthosis (FO), nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3961 | Shoulder-elbow-wrist-hand orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3967 | Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3971 | Shoulder-elbow-wrist-hand orthotic (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3973 | Shoulder-elbow-wrist-hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3975 | Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3976 | Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3977 | Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L3978 | Shoulder-elbow-wrist-hand-finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment | 3/8/2021 |
| L4030 | Replace quadrilateral socket brim, custom fitted | 3/8/2021 |
| L4040 | Replace molded thigh lacer, for custom fabricated orthosis only | 3/8/2021 |
| L4045 | Replace nonmolded thigh lacer, for custom fabricated orthosis only | 3/8/2021 |
| L4050 | Replace molded calf lacer, for custom fabricated orthosis only | 3/8/2021 |
| L4055 | Replace nonmolded calf lacer, for custom fabricated orthosis only | 3/8/2021 |
| L4396 | Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 3/8/2021 |
| L4631 | Ankle-foot orthosis (AFO), walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated | 3/8/2021 |
| L0130 | Cervical, flexible, thermoplastic collar, molded to patient | 3/8/2021 |
| L0170 | Cervical, collar, molded to patient model | 3/8/2021 |
| L0700 | Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-posterior-lateral control, molded to patient model, (Minerva type) | 3/8/2021 |
| L0710 | Cervical-thoracic-lumbar-sacral orthosis (CTLSO), anterior-posterior-lateral control, molded to patient model, with interface material, (Minerva type) | 3/8/2021 |
| L1110 | Addition to cervical-thoracic-lumbar-sacral orthosis (CTLSO) or scoliosis orthosis, ring flange, plastic or leather, molded to patient model | 3/8/2021 |
| L2250 | Addition to lower extremity, foot plate, molded to patient model, stirrup attachment | 3/8/2021 |
| L2510 | Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model | 3/8/2021 |
| L2525 | Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model | 3/8/2021 |
| L2530 | Addition to lower extremity, thigh/weight bearing, lacer, nonmolded | 3/8/2021 |
| L2627 | Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables | 3/8/2021 |
| L3001 | Foot, insert, removable, molded to patient model, Spenco, each | 3/8/2021 |
| L3002 | Foot insert, removable, molded to patient model, Plastazote or equal, each | 3/8/2021 |
| L3003 | Foot insert, removable, molded to patient model, silicone gel, each | 3/8/2021 |
| L3040 | Foot, arch support, removable, premolded, longitudinal, each | 3/8/2021 |
| L3050 | Foot, arch support, removable, premolded, metatarsal, each | 3/8/2021 |
| L3251 | Foot, shoe molded to patient model, silicone shoe, each | 3/8/2021 |
| L4020 | Replace quadrilateral socket brim, molded to patient model | 3/8/2021 |
Make note that the following HCPCS Codes no longer require a prior authorization:
- Codes 78071 and 78072 for Single-photon Emission Computerized Tomography (SPECT) Scans
- Code 92620 for Auditory Function Evaluation of central auditory function, with report; initial 60 minutes
How this impacts providers: Providers should follow the prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days.
Next steps for providers: Providers should inform their staff of these prior authorization requirements.
If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
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