Policy Updates Prior AuthorizationCommercialMarch 1, 2024

Precertification list change notification — March 1, 2024

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

To obtain precertification, providers can access Availity.com or call the Utilization Management department for Anthem 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-MED-88

Preimplantation Embryo Biopsy and Genetic Testing

0254U

June 1, 2024

CG-MED-88

Preimplantation Embryo Biopsy and Genetic Testing

0396U

June 1, 2024

CG-OR-PR-08

Microprocessor Controlled Lower Limb Prosthesis

L7510

June 1, 2024

CG-OR-PR-08

Microprocessor Controlled Lower Limb Prosthesis

L7520

June 1, 2024

CG-SURG-61

Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

53850

June 1, 2024

CG-SURG-61

Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

53852

June 1, 2024

CG-SURG-61

Cryosurgical, Radiofrequency, Microwave or Laser Ablation to Treat Solid Tumors Outside the Liver

C9751

June 1, 2024

DME.00011

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

E0769

June 1, 2024

DME.00041

Ultrasonic Diathermy Devices

K1036

June 1, 2024

DME.00043

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

E0490

June 1, 2024

DME.00043

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

E0491

June 1, 2024

Carelon Medical Benefits Management, Inc. Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0403U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0411U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0419U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0262U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0405U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0409U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0410U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0413U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0414U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0415U

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0417U

June 1, 2024

LAB.00011

Selected Protein Biomarker Algorithmic Assays

0342U

June 1, 2024

LAB.00028

Blood-based Biomarker Tests for Multiple Sclerosis

0361U

June 1, 2024

LAB.00040

Serum Biomarker Tests for Risk of Preeclampsia

0390U

June 1, 2024

LAB.00041

Machine Learning Derived Probability Score for Rapid Kidney Function Decline

0407U

June 1, 2024

LAB.00046

Testing for Biochemical Markers for Alzheimer’s Disease

0412U

June 1, 2024

MED.00143

Ingestible Devices for the Treatment of Constipation

A9268

June 1, 2024

MED.00143

Ingestible Devices for the Treatment of Constipation

A9269

June 1, 2024

MED.00145

Digital Therapy Devices for Treatment of Amblyopia

A9292

June 1, 2024

SURG.00011

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

A2022

June 1, 2024

SURG.00011

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

A2023

June 1, 2024

SURG.00011

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

A2024

June 1, 2024

SURG.00011

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

A2025

June 1, 2024

SURG.00011

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

C1832

June 1, 2024

SURG.00011

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

Q4285

June 1, 2024

SURG.00011

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

Q4286

June 1, 2024

SURG.00026

Deep Brain, Cortical, and Cerebellar Stimulation

C1787

June 1, 2024

SURG.00071

Percutaneous and Endoscopic Spinal Surgery

C2614

June 1, 2024

SURG.00144

Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

64505

June 1, 2024

TRANS.00009

Portable Normothermic Organ Perfusion Systems

0494T

June 1, 2024

TRANS.00009

Portable Normothermic Organ Perfusion Systems

0495T

June 1, 2024

TRANS.00009

Portable Normothermic Organ Perfusion Systems

0496T

June 1, 2024

Carelon Medical Benefits Management Guidelines

Carelon Medical Benefits Management Genetic Testing Guideline

0088U

June 1, 2024

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CTBCBS-CM-049467-24-CPN49255

PUBLICATIONS: March 2024 Provider Newsletter