016-06-10 Ark. Code R. § 18
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