Policy Updates Prior AuthorizationCommercialJuly 1, 2024

Precertification list change notification July 1, 2024

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity (Availity.com) or call Anthem’s

Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider. 

Add to precertification

Criteria

Criteria description

Code

Effective date

CG-DME-06

Compression Devices for Lymphedema

E0678

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0679

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0680

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0681

10/1/2024

CG-DME-06

Compression Devices for Lymphedema

E0682

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33276

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33277

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33278

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33279

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33280

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33281

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33287

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

33288

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93150

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93151

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93152

10/1/2024

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

93153

10/1/2024

CG-SURG-83

Bariatric Surgery and Other Treatments for Clinically Severe Obesity

0813T

10/1/2024

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

A4540

10/1/2024

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

E0732

10/1/2024

DME.00042

Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea

E0530

10/1/2024

DME.00043

Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring

E0492

10/1/2024

DME.00043

Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring

E0493

10/1/2024

DME.00046

Intermittent Abdominal Pressure Ventilation Devices

A4468

10/1/2024

DME.00049

External Upper Limb Stimulation for the Treatment of Tremors

A4542

10/1/2024

DME.00049

External Upper Limb Stimulation for the Treatment of Tremors

E0734

10/1/2024

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

0423U

10/1/2024

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

0434U

10/1/2024

GENE.00010

Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status

0438U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81457

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81458

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81459

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81462

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81463

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

81464

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0422U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0424U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0425U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0426U

10/1/2024

GENE.00052

Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

0428U

10/1/2024

GENE.00056

Gene Expression Profiling for Bladder Cancer

0420U

10/1/2024

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

0435U

10/1/2024

LAB.00016

Fecal Analysis in the Diagnosis of Intestinal Disorders

0430U

10/1/2024

LAB.00019

Proprietary Algorithms for Liver Fibrosis

Previously titled: Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

81517

10/1/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

0112U

10/1/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

0152U

10/1/2024

LAB.00050

Metagenomic Sequencing for Infectious Disease in the Outpatient Setting

0323U

10/1/2024

MED.00130

Surface Electromyography and Electrodermal Activity Sensor Devices for Seizure Monitoring

E0746

10/1/2024

RAD.00068

Myocardial Strain Imaging

C9762

10/1/2024

RAD.00068

Myocardial Strain Imaging

C9763

10/1/2024

SURG.00007

Vagus Nerve Stimulation

E0735

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4279

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4287

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4288

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4289

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4290

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4291

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4292

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4293

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4294

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4295

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4296

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4297

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4298

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4299

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4300

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4301

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4302

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4303

10/1/2024

SURG.00011

Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4304

10/1/2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

61889

10/1/2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

61891

10/1/2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

C1778

10/1/2024

SURG.00045

Extracorporeal Shock Wave Therapy

0864T

10/1/2024

SURG.00077

Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques

58580

10/1/2024

SURG.00097

Scoliosis Surgery

22836

10/1/2024

SURG.00097

Scoliosis Surgery

22837

10/1/2024

SURG.00097

Scoliosis Surgery

22838

10/1/2024

SURG.00097

Scoliosis Surgery

0790T

10/1/2024

SURG.00142

Genicular Procedures for Treatment of Knee Pain

Previously titled: Genicular Nerve Blocks and Ablation for Chronic Knee Pain

37242

10/1/2024

SURG.00150

Leadless Pacemaker

0823T

10/1/2024

SURG.00150

Leadless Pacemaker

0824T

10/1/2024

SURG.00150

Leadless Pacemaker

0825T

10/1/2024

SURG.00150

Leadless Pacemaker

0826T

10/1/2024

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

0861T

10/1/2024

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

0862T

10/1/2024

SURG.00152

Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing

0863T

10/1/2024

SURG.00157

Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

31242

10/1/2024

SURG.00157

Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

31243

10/1/2024

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

64596

10/1/2024

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

64597

10/1/2024

UM AROW# A2024M1436

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PUBLICATIONS: July 2024 Provider Newsletter