Policy Updates Prior AuthorizationMedicare AdvantageJuly 25, 2023

Prior authorization requirement changes effective November 1, 2023

Effective November 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield for Medicare 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 precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Code

Code description

0377U

Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile 

0378U

RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab

0379U

Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop

0380U

Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and

0687T

Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session

0688T

Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report

0704T

Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment

0705T

Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hour

0706T

Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month

0778T

Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle

A2019

Kerecis omega3 marigen shield, per square centimeter

A2020

Ac5 advanced wound system (ac5)

A2021

Neomatrix, per square centimeter

A4341

Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each

A4342

Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each

E1905

Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software

Q4265

Neostim tl, per square centimeter

Q4266

Neostim membrane, per square centimeter

Q4267

Neostim dl, per square centimeter

Q4268

Surgraft ft, per square centimeter

Q4269

Surgraft xt, per square centimeter

Q4270

Complete sl, per square centimeter

Q4271

Complete ft, per square centimeter

Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://www.anthem.com/provider/news/archives/ > Providers > Claims > Prior Authorization or for contracted providers by accessing Availity.com.* 

UM AROW 4505
*Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

MULTI-BCBS-CR-028190-23-CPN27641

PUBLICATIONS: August 2023 Provider Newsletter