Prior authorization requirements: new 2020 codes for coverage and precertification

Effective June 1, 2020, prior authorization (PA) requirements will change for the following services to be covered for Anthem Blue Cross 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. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

• 0156U — Copy number (for example, intellectual disability, dysmorphology), sequence analysis
• 0157U — APC (APC regulator of WNT signaling pathway) (for example, familial adenomatosis polyposis [FAP]) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0158U — MLH1 (mutL homolog 1) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0159U — MSH2 (mutS homolog 2) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0160U — MSH6 (mutS homolog 6) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0161U — PMS2 (PMS1 homolog 2, mismatch repair system component) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0569T — Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis
• 0570T — Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (list separately in addition to code for primary procedure)
• 0571T — Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed
• 0572T — Insertion of substernal implantable defibrillator electrode
• 0587T — Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T — Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 64624 — Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
• 81277 — Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities
• E0787 — External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing
• E2398 — Wheelchair accessory, dynamic positioning hardware for back
• J0179 — Injection, brolucizumab- dbll, 1 mg

 

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

• Web: https://www.availity.com
• Fax: 1-800-754-4708
• Phone: 1-888-831-2246

 

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com by visiting https://mediproviders.anthem.com/ca > Login. Contracted and noncontracted providers who are unable to access Availity* may call one of our Medi-Cal Managed Care Customer Care Centers at 1‑800‑407‑4627 (outside L.A. County) or 1‑888‑285‑7801 (inside L.A. County) for PA requirements.