MedicaidNovember 5, 2024
Prior authorization requirement changes
Effective March 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid 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 |
E0468 | Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions |
E0482 | Cough stimulating device, alternating positive and negative airway pressure |
J0687 | Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg |
J0688 | Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg |
J0689 | Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg |
J2183 | Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg |
J2184 | Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg |
J2281 | Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg |
Q4311 | Acesso, per sq cm |
Q4312 | Acesso AC, per sq cm |
Q4313 | DermaBind FM, per sq cm |
Q4314 | Reeva FT, per sq cm |
Q4315 | RegeneLink Amniotic Membrane Allograft, per sq cm |
Q4316 | AmchoPlast, per sq cm |
Q4317 | VitoGraft, per sq cm |
Q4318 | E-Graft, per sq cm |
Q4319 | SanoGraft, per sq cm |
Q4320 | PelloGraft, per sq cm |
Q4321 | RenoGraft, per sq cm |
Q4322 | CaregraFT, per sq cm |
Q4323 | alloPLY, per sq cm |
Q4324 | AmnioTX, per sq cm |
Q4325 | ACApatch, per sq cm |
Q4326 | WoundPlus, per sq cm |
Q4327 | DuoAmnion, per sq cm |
Q4328 | MOST, per sq cm |
Q4329 | Singlay, per sq cm |
Q4330 | TOTAL, per sq cm |
Q4331 | Axolotl Graft, per sq cm |
Q4332 | Axolotl DualGraft, per sq cm |
Q4333 | ArdeoGraft, per sq cm |
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:
- 888-831-2246 for Medi-Cal Managed Care
- 877-273-4193 for Major Risk Medical Insurance Program
Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Medi-Cal Customer Care Centers for assistance with PA requirements:
- Outside L.A. County: 800-407-4627
- L.A. County: 888-285-7801
UM AROW A2024M2366
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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