Prior Authorization Updates Effective Date: April 26, 2021

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Prior Authorization Updates Effective Date: April 26, 2021 Notice Date: May 26, 2021 To: Georgia Medicaid Providers From: CareSource Subject: Prior Authorization Updates Effective Date: April 26, 2021 CareSource values our partnership with our providers. As result of your feedback, and to support you in these unprecedented times, we have adjusted prior authorization requirements. The addendum to this announcement includes codes that are being removed from requiring prior authorization. We are pleased to present this change and reduce the administrative burden to our providers. Providers should use the Procedure Code Lookup Tool to instantly view whether a service code requires prior authorization from CareSource. Effective April 26, 2021, the tool reflects that the codes in the addendum do not require prior authorization from CareSource. Questions? For questions related to prior authorization requirements, providers may contact CareSource Utilization Management at 1-855-202-1058. Our hours of operation are Monday to Friday, 7 a.m. to 7 p.m., Eastern Standard Time. GA-MED-P-566425 DCH Approved: 5/14/2021 Addendum – Codes Removed from Prior Authorization Effective April 26, 2021 Code Description Category Product Filing Category 10030 Image‐guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst) Ambulatory Surgery Elective Surgery‐Diagnostic 10120 Incision and removal of foreign body, subcutaneous tissues; simple Ambulatory Surgery Elective Surgery‐Dermatology 10121 Incision and removal of foreign body, subcutaneous tissues; complicated Ambulatory Surgery Elective Surgery‐Dermatology 10180 Incision and drainage, complex, postoperative wound infection Ambulatory Surgery Elective Surgery‐Dermatology 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface Ambulatory Surgery Elective Surgery‐Dermatology 11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent m Ambulatory Surgery Elective Surgery‐Dermatology 11010 Debridement including removal of foreign material at the site of an open fracture and/or an open dis Ambulatory Surgery Elective Surgery‐Dermatology 11011 Debridement including removal of foreign material at the site of an open fracture and/or an open dis Ambulatory Surgery Elective Surgery‐Dermatology 11012 Debridement including removal of foreign material at the site of an open fracture and/or an open dis Ambulatory Surgery Elective Surgery‐Dermatology 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if perform Ambulatory Surgery Elective Surgery‐Dermatology 11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed Ambulatory Surgery Elective Surgery‐Dermatology 11103 Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); each separate/additional lesion (L Ambulatory Surgery Elective Surgery‐Dermatology 11105 Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (Li Ambulatory Surgery Elective Surgery‐Dermatology 11107 Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each separate/addi Ambulatory Surgery Elective Surgery‐Dermatology 11313 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membra Ambulatory Surgery Elective Surgery‐Dermatology 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or Ambulatory Surgery Elective Surgery‐Dermatology Code Description Category Product Filing Category 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or Ambulatory Surgery Elective Surgery‐Dermatology 11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or Ambulatory Surgery Elective Surgery‐Dermatology 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or Ambulatory Surgery Elective Surgery‐Dermatology 11404 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or Ambulatory Surgery Elective Surgery‐Dermatology 11406 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or Ambulatory Surgery Elective Surgery‐Dermatology 11420 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, h Ambulatory Surgery Elective Surgery‐Dermatology 11421 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, h Ambulatory Surgery Elective Surgery‐Dermatology 11422 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, h Ambulatory Surgery Elective Surgery‐Dermatology 11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, h Ambulatory Surgery Elective Surgery‐Dermatology 11424 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, h Ambulatory Surgery Elective Surgery‐Dermatology 11426 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, h Ambulatory Surgery Elective Surgery‐Dermatology 11440 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ea Ambulatory Surgery Elective Surgery‐Dermatology 11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ea Ambulatory Surgery Elective Surgery‐Dermatology 11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ea Ambulatory Surgery Elective Surgery‐Dermatology 11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ea Ambulatory Surgery Elective Surgery‐Dermatology 11444 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ea Ambulatory Surgery Elective Surgery‐Dermatology Code Description Category Product Filing Category 11446 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ea Ambulatory Surgery Elective Surgery‐Dermatology 11450 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate rep Ambulatory Surgery Elective Surgery‐Dermatology 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Ambulatory Surgery Elective Surgery‐Dermatology 11462 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate rep Ambulatory Surgery Elective Surgery‐Dermatology 11463 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Ambulatory Surgery Elective Surgery‐Dermatology 11470 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with si Ambulatory Surgery Elective Surgery‐Dermatology 11471 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with co Ambulatory Surgery Elective Surgery‐Dermatology 11601 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm Ambulatory Surgery Elective Surgery‐Dermatology 11602 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm Ambulatory Surgery Elective Surgery‐Dermatology 11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm Ambulatory Surgery Elective Surgery‐Dermatology 11604 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm Ambulatory Surgery Elective Surgery‐Dermatology 11606 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm Ambulatory Surgery Elective Surgery‐Dermatology 11622 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter Ambulatory Surgery Elective Surgery‐Dermatology 11623 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter Ambulatory Surgery Elective Surgery‐Dermatology 11624 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter Ambulatory Surgery Elective Surgery‐Dermatology 11626 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter Ambulatory Surgery Elective Surgery‐Dermatology Code Description Category Product Filing Category 11641 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 Ambulatory Surgery Elective Surgery‐Dermatology 11642 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 Ambulatory Surgery Elective Surgery‐Dermatology 11643 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 Ambulatory Surgery Elective Surgery‐Dermatology 11644 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 Ambulatory Surgery Elective Surgery‐Dermatology 11646 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over Ambulatory Surgery Elective Surgery‐Dermatology 11750 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent Ambulatory Surgery Elective Surgery‐Dermatology 11771 Excision of pilonidal cyst or sinus; 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