Prior authorization requirements changes effective November 1, 2019

Category: Medicare

 

This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).

 

Effective November 1, 2019, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem for Medicaid and Medicare Advantage 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:

• 0026U -- Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result
• 0533T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes setup, patient training, configuration
• 0534T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; setup, patient training, configuration of monitor
• 0535T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
• 0536T -- Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
• 0546T -- Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
• 33270 -- Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation
• 33271 -- Insertion of subcutaneous implantable defibrillator electrode
• 77299 -- Unlisted procedure, therapeutic radiology clinical treatment planning
• 81205 -- BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (for example, Maple syrup urine disease) gene analysis, common variants (for example, R183P, G278S, E422X)
• 81219 -- CALR (calreticulin) (for example, myeloproliferative disorders), gene analysis, common variants in exon 9
• 81250 -- G6PC (glucose-6-phosphatase, catalytic subunit) (for example, Glycogen storage disease, Type 1a, von Gierke disease) gene analysis, common variants (for example, R83C, Q347X)
• 81302 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; full sequence analysis
• 81303 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; known familial variant
• 81304 -- MECP2 (methyl CpG binding protein 2) (for example, Rett syndrome) gene analysis; duplication/deletion variants
• 81331 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81332 -- SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (for example, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis
• 81400 -- Molecular pathology procedure, Level 1 (for example, identification of single germline variant for example, SNP by techniques such as restriction enzyme digestion or melt curve analysis)ACADM (acyl—CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (for example, medium chain acyl dehydrogenase deficiency)
• 81401 -- Molecular pathology procedure, Level 2 (for example, 2-10 SNPs, 1 methylated variant, or 1 somatic variant typically using nonsequencing target variant analysis, or detection of a dynamic mutation disorder/triplet repeat) ABL (c-abl oncogene 1, receptor tyrosine kinase) (for example, acquired imatinib resistance)
• 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81402 -- Molecular pathology procedure, Level 3 (for example, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants typically using nonsequencing target variant analysis, immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants 1 exon) CYP21A2 (cytochrome P450, family 21, subfamily A, polypeptide 2) (for example, congenital adrenal hyperplasia, 21-hydroxylase deficiency), common variants (for example, IVS2-13G, P30L, I172N, exon 6 mutation cluster I235N, V236E, M238K)
• 81407 -- Molecular pathology procedure, Level 8 (for example, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) SCN1A (sodium channel, voltage-gated, type 1, alpha subunit) (for example, generalized epilepsy with febrile seizures), full gene sequence
• 81408 -- Molecular pathology procedure, Level 9 (for example, analysis of >50 exons in a single gene by DNA sequence analysis) FBN1 (fibrillin 1) (for example, Marfan syndrome), full gene sequence NF1 (neurofibromin 1) (for example, neurofibromatosis, type 1), full gene sequence RYR1 (ryanodine receptor 1, skeletal) (for example, malignant hyperthermia), full gene sequence VWF (von Willebrand factor) (for example, von Willebrand disease types 1 and 3), full gene sequence
• 97033 -- Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
• C9042 -- Injection, bendamustine hcl (belrapzo), 1 mg
• C9043 -- Injection, levoleucovorin, 1 mg
• C9141 -- Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi)
• D9130 -- Temporomandibular Joint Dysfunction – Non-Invasive Physical Therapies
• D9920 -- or management, by report
• J9999 -- Not otherwise classified, antineoplastic drugs
• S3850 -- Genetic testing for sickle cell anemia

 

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

• Web: https://www.Availity.com
• Fax: 1-800-964-3627
• Phone: 1-844-396-2330

 

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.Availity.com. Contracted and noncontracted providers who are unable to access Availity may call our Provider Services at 1-844-396-2330 for assistance with PA requirements. To reach Medicare Advantage Provider Services, call the number on the back of members’ ID cards.

 

ANV-NU-0074-19 August 2019          503100MUPENMUB