Policy Updates Prior AuthorizationMedicaidNovember 5, 2024

Prior authorization requirement changes

Effective March 1, 2025

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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