Policy Updates Prior AuthorizationMedicaidJune 11, 2024

Prior authorization requirement changes

Effective October 1, 2024

Effective October 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medi-Cal members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines (including definitions and specific contract provisions/exclusions), take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Code

Description

81173

AR (androgen receptor) (such as, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence

81247

G6PD (glucose-6-phosphate dehydrogenase) (such as, hemolytic anemia, jaundice), gene analysis; common variant(s) (such as, A, A-)

81249

G6PD (glucose-6-phosphate dehydrogenase) (such as, hemolytic anemia, jaundice), gene analysis; full gene sequence

81307

PALB2 (partner and localizer of BRCA2) (such as, breast and pancreatic cancer) gene analysis; full gene sequence

81336

SMN1 (survival of motor neuron 1, telomeric) (such as, spinal muscular atrophy) gene analysis; full gene sequence

81403

Molecular pathology procedure, Level 4 (such as, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons):

EPCAM (epithelial cell adhesion molecule) (such as, Lynch syndrome), duplication/deletion analysis.

81405

Molecular pathology procedure, Level 6 (such as, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, (such as targeted cytogenomic array analysis) [when specified as the following]:

ARSA (arylsulfatase A) (such as, arylsulfatase A deficiency), full gene sequence
BCKDHA (branched chain keto acid dehydrogenase E1, alpha polypeptide) (such as, maple syrup urine disease, type 1A), full gene sequence
DBT (dihydrolipoamide branched chain transacylase E2) (such as, maple syrup urine disease type 2), duplication/deletion analysis
DHCR7 (7-dehydrocholesterol reductase) (such as, Smith-Lemli-Opitz syndrome), full gene sequence
GLA (galactosidase, alpha) (such as, Fabry disease), full gene sequence
NLGN3 (neuroligin 3) (such as, autism spectrum disorders), full gene sequence;
NLGN4X (neuroligin 4, X-linked) (such as, autism spectrum disorders), full gene sequence
OTC (ornithine carbamoyltransferase) (such as, ornithine transcarbamylase deficiency), full gene sequence
TGFBR1 (transforming growth factor, beta receptor 1) (such as, Marfan syndrome), full gene sequence
TGFBR2 (transforming growth factor, beta receptor 2) (such as, Marfan syndrome), full gene sequence

81440

Nuclear encoded mitochondrial genes (such as, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP

To request PA, you may use one of the following methods:

  • Web: Once logged in to Availity Essentials at Availity.com. 
  • Fax: 800-754-4708
  • Phone: 
    • Medi-Cal: 888-831-2246
    • MRMIP: 877-273-4193

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity.com. For assistance with PA requirements, Providers may also call Provider Services at 800-407-4627 outside of Los Angeles County, and 888-258-7801 within Los Angeles County. 

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: July 2024 Provider Newsletter