On December 1, 2020, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

Prior authorization requirements will be added for the following codes:

  • C1764 Event recorder, cardiac (implantable)
  • E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED
  • E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,
  • E0731 Conductive Garment For Tens
  • G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
  • L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each
  • L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength
  • L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
  • L3224 Woman's Shoe Oxford Brace
  • L3225 Man's Shoe Oxford Brace
  • L3300 Shoe Lift Taper To Metatarsal
  • L3310 Lift, elevation, heel and sole, neoprene, per in
  • L3332 Lift, elevation, inside shoe, tapered, up to one-half in
  • L3334 Lift, elevation, heel, per in
  • L3340 Heel wedge, SACH
  • L3350 Shoe Heel Wedge
  • L3370 Shoe Sole Wedge Between Sole
  • L3390 Shoe Outflare Wedge
  • L3400 Shoe Metatarsal Bar Wedge Ro
  • L3450 Shoe Heel Sach Cushion Type
  • L3485 Shoe Heel Pad Removable For
  • L3540 Ortho Shoe Add Full Sole
  • L3580 O Shoe Add Instep Velcro Clo
  • L3610 Transfer of an orthosis from one shoe to another, caliper plate, new
  • L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing
  • L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new
  • L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
  • L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
  • L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
  • L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf
  • L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
  • L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
  • L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf
  • L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
  • L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated,

off-the-shelf

  • L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
  • L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated,

off-the-shelf

  • L3999 Upper Limb Orthosis Nos
  • L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
  • L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
  • L5620 Test Socket Below Knee
  • L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame
  • L5649 Addition to lower extremity, ischial containment/narrow M-L socket
  • L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
  • 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
  • 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure.)
  • 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
  • 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure.)
  • 0480T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure.)
  • 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
  • 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
  • 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
  • 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
  • 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)
  • 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis
  • 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
  • 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
  • 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle
  • 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only
  • 36514 Therapeutic Apheresis; Plasma Pheresis
  • 36522 Photopheresis, Extracorporeal
  • 37215 Transcatheter Placement Of Intravascular Stent(S), Cervical Carotid Artery, Percutaneous; With Distal Embolic Protection
  • 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
  • A4224 Supplies for maintenance of insulin infusion catheter, per week
  • A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
  • A5500 Diabetic Shoe For Density Insert
  • A5501 Diabetic Custom Molded Shoe
  • A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
  • A5504 Diabetic Shoe With Wedge
  • A5505 Diabetic Shoe W/Metatarsal Bar
  • A5507 Modification Diabetic Shoe
  • A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah
  • A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
  • A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries
  • C1722 Cardioverter-defibrillator, single chamber (implantable)
  • L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert
  • L5673 Addition to lower extremity, below knee/above knee, custom fabricated
  • L5679 Addition to lower extremity, below knee/above knee, custom fabricated
  • L5700 Replace Socket Below Knee
  • L5701 Replace Socket Above Knee
  • L5940 Endo Bk Ultra-Light Material
  • L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
  • L5981 All lower extremity prostheses, flex-walk system or equal
  • L5987 All lower extremity prostheses, shank foot system with vertical loading pylon
  • L8699 Prosthetic implant, not otherwise specified
  • L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

 

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at availity.com at anthem.com/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.



* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.
ABSCRNU-0172-20



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October 2020 Anthem Provider News - Georgia