Effective February 1, 2020, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross for Medi-Cal Managed Care members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

  • 43238: esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus
  • 43242: esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound)
  • 43253: esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s)
  • 78459: myocardial imaging, positron emission tomography (PET), metabolic evaluation
  • 78491: myocardial PET; single study, rest/stress
  • 78492: myocardial PET; multiple studies, rest and/or stress
  • 78608: brain imaging, PET; metabolic evaluation
  • 78609: brain imaging, PET; perfusion evaluation
  • 78811: PET imaging; limited area (for example, chest, head/neck)
  • 78812: PET imaging; skull base to mid-thigh
  • 78813: PET imaging; skull base to mid-thigh
  • 78814: PET with concurrently acquired computed tomography (CT) for attenuation correction
  • 78815: PET with concurrently acquired CT for attenuation correction
  • 78816: PET with concurrently acquired CT for attenuation correction
  • 81227: Cyp2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (for example, drug metabolism), gene analysis, common variants (for example, *2, *3, *5, *6)
  • 81231: CYP3A5 (cytochrome P450, family 3, subfamily A, member 5) (for example, drug metabolism), gene analysis, common variants (including *2, *3, *4, *5, *6, *7)
  • 81232: DPYD (dihydropyrimidine dehydrogenase) (for example, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (including *2A, *4, *5, *6)
  • 81346: TYMS (thymidylate synthetase) (for example, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (for example, tandem repeat variant)
  • 0031U: CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(for example, drug metabolism) gene analysis, common variants (including *1F, *1K, *6, *7)
  • 0032U: COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G > A (rs4680) variant
  • 0070U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, common and select rare variants (including *2, *3, *4, *4N, *5, *6, *7, *8, *9)
  • 0072U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including CYP2D6 to 2D7 hybrid gene)
  • 0073U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including CYP2D7 to 2D6 hybrid gene)
  • 0074U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including nonduplicated gene)
  • 0075U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including 5 gene duplication/ multiplication)
  • 0076U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis
  • 0091U: oncology (colorectal) screening, cell enumeration of circulating tumor cells, utilizing whole blood, algorithm, for the presence of adenoma or cancer, reported as a positive or negative result
  • 0092U: oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy
  • 0093U: prescription drug monitoring, evaluation of 65 common drugs by LC-MS/MS, urine, each drug reported detected or not detected
  • 0098U: respiratory pathogen, multiplex reverse transcription and multiplex amplified probe technique, multiple types or subtypes, 14 targets
  • 0099U: respiratory pathogen, multiplex reverse transcription and multiplex amplified probe technique, multiple types or subtypes, 20 targets (adenovirus, coronavirus 229E, coronavirus)
  • 0100U: respiratory pathogen, multiplex reverse transcription and multiplex amplified probe technique, multiple types or subtypes, 21 targets (adenovirus, coronavirus 229E, coronavirus)
  • J9036: injection, bendamustine hydrochloride (Belrapzo®), 1 mg
  • 81479: unlisted molecular pathology procedure
  • 81599: unlisted multianalyte assay with algorithmic analysis
  • 0094U: genome (for example, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis
  • 0101U: hereditary colon cancer disorders (for example, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis)
  • 0102U: hereditary breast cancer-related disorders (for example, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer)
  • 0103U: hereditary ovarian cancer (for example, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of next-generation sequencing, Sanger sequencing, multiplex ligation-dependent probe amplification
  • 0408T: insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed and programming of sensing and therapeutic parameters
  • 0409T: insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed and programming of sensing and therapeutic parameters
  • 0410T: insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed and programming of sensing and therapeutic parameters
  • 0411T: insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed and programming of sensing and therapeutic parameters
  • 0412T: removal of permanent cardiac contractility modulation system; pulse generator only
  • 0413T: removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)
  • 0414T: removal and replacement of permanent cardiac contractility modulation system pulse generator only
  • 0415T: repositioning of previously implanted cardiac contractility modulation transvenous electrode (atrial or ventricular lead)
  • 0416T: relocation of skin pocket for implanted cardiac contractility modulation pulse generator
  • 0417T: programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values
  • 0418T: interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac
  • 0512T: extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound
  • 0513T: extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound
  • 0544T: transcatheter mitral valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach, including transseptal puncture
  • 0545T: transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach
  • 0548T: transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy
  • 0549T: transperineal periurethral balloon continence device; unilateral placement, including cystoscopy and fluoroscopy
  • 0550T: transperineal periurethral balloon continence device; removal, each balloon
  • 0551T: transperineal periurethral balloon continence device; adjustment of balloon(s) fluid volume
  • E2599: accessory for speech generating device, not otherwise classified
  • G9143: warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)
  • J3490: unclassified drugs (Avastin®, Mvasi™)
  • S3870: comparative genomic hybridization microarray testing for developmental delay, autism spectrum disorder and/or intellectual disability

 

Request PA via:

  • Fax: 1-844-474-3345
  • Phone: Medi-Cal Customer Care Centers:
    • 1-800-407-4627 (outside L.A. County)
    • 1-888-285-7801 (inside L.A. County).

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the Provider Self-Service Tool on the Availity Portal by going to

https://mediproviders.anthem.com/ca > Login.

 

Contracted and noncontracted providers unable to access Availity can go to https://mediproviders.anthem.com/ca > Prior Authorization & Claims > Prior Authorization Lookup Tool or call one of our Medi-Cal Customer Care Centers at 1-800-407-4627 (outside L.A. County) or 1-888-285-7801 (inside L.A. County) for assistance with PA.



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December 2019 Anthem Blue Cross Provider News - California