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HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 54150
AUTHORIZATION REQUIRED
| PR CIRCUMCISION,CLAMP,OTHER DEVICE WITH REGIONAL DORSAL PENILE OR RING BLOCK | CHIP, STAR, STAR KIDS | CHIP PERINATE | 1/1/2024 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | AGE: PRIOR AUTH IS REQUIRED IF OLDER THAN 1 YEAR., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR | TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 54160
AUTHORIZATION REQUIRED
| PR CIRCUMCISION,OTHER,<28 D/O | CHIP, STAR, STAR KIDS | CHIP PERINATE | 1/1/2024 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | AGE: PRIOR AUTH IS REQUIRED IF OLDER THAN 1 YEAR., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR | TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 54161
AUTHORIZATION REQUIRED
| PR CIRCUMCISION,OTHER,28+ D/O | CHIP, STAR, STAR KIDS | CHIP PERINATE | 1/1/2024 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | AGE: PRIOR AUTH IS REQUIRED IF OLDER THAN 1 YEAR., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR | TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 54162
AUTHORIZATION REQUIRED
| PR LYSIS/EXCIS,PENILE POSTCIRCUM ADHESIONS | CHIP, STAR, STAR KIDS | CHIP PERINATE | 1/1/2024 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | AGE: PRIOR AUTH IS REQUIRED IF OLDER THAN 1 YEAR., EXCLUSIONS: AUTH REQUIRED UNLESS DHP IS A SECONDARY PAYOR | TMPPM, HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |