016.06.10 Ark. Code R. 018
Health Care Provider - Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD) and Physician/Independent Lab/CRNA/Radiation Therapy Center, July 1, 2011, Prior Authorization for Procedure Codes 87901, 87903, and 87904
Effective for claims with dates of service on or after July 1, 2011, the following procedure codes will no longer require a prior authorization when the primary (ICD-9-CM) diagnosis is 042, Human Immunodeficiency Virus (HIV) disease:
Procedure Code | Description | Limitations |
87901 | Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions | A maximum of 12 units per 12 month period |
87903 | Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV-1; first through ten drugs tested | A maximum of 1 unit per year |
87904 | Each additional drug tested (List separately in addition to code for primary procedure) | This procedure code is an add-on code. |
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016.06.10 Ark. Code R. 018