Medicare AdvantageMarch 6, 2025
Prior authorization requirement changes
Effective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for 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 precertification rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity or by calling Provider Services with additional information which may include medical records.
Prior authorization requirements will be added for the following code(s):
Code | Description |
0108U | Gastroenterology (Barrett's esophagus), whole slide‑digital imaging, including morphometric analysis, computer‑assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, CD68, COX‑2, CD45RO, HIF1a, HER‑2, K20) and morphology, formalin‑fixed paraffin‑embedded tissue, algorithm reported as risk of progression to high‑grade dysplasia or cancer |
0394U | Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), plasma or serum, quantitative |
0457U | Perfluoroalkyl substances (PFAS) (for example, perfluorooctanoic acid, perfluorooctane sulfonic acid), 9 PFAS compounds by LC‑MS/MS, plasma or serum, quantitative |
0479U | Tau, phosphorylated, pTau217 |
0480U | Infectious disease (bacteria, viruses, fungi, and parasites), cerebrospinal fluid (CSF), metagenomic next‑generation sequencing (DNA and RNA), bioinformatic analysis, with positive pathogen identification |
0482U | Obstetrics (preeclampsia), biochemical assay of soluble fms‑like tyrosine kinase 1 (sFlt‑1) and placental growth factor (PlGF), serum, ratio reported for sFlt‑1/PlGF, with risk of progression for preeclampsia with severe features within 2 weeks |
0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular‑weight melanoma‑associated antigen, CD34 and CD45 protein biomarkers, peripheral blood |
0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen receptor (ER) protein biomarker‑expressing cells, peripheral blood |
0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD‑L1 protein biomarker‑expressing cells, peripheral blood |
0495U | Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer |
0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau‑protein (ptau217, np‑tau217, ptau217/np‑tau217 ratio), blood, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC‑MS/MS), algorithm score reported as likelihood of positive or negative for amyloid plaques |
0517U | Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non‑prescribed medications |
0518U | Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, LC‑MS/MS, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non‑prescribed medications |
0519U | Therapeutic drug monitoring, medications specific to pain, depression, and anxiety, LC‑MS/MS, plasma, 110 or more drugs or substances, qualitative and quantitative therapeutic minimally effective range of prescribed, non‑prescribed, and illicit medications in circulation |
0915T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous electrodes/leads (pacing and defibrillation) |
0916T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator only |
0917T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; single transvenous lead (pacing or defibrillation) only |
0918T | Insertion of permanent cardiac contractility modulation‑defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; dual transvenous leads (pacing and defibrillation) only |
0919T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); pulse generator only |
0920T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous pacing lead only |
0921T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); single transvenous defibrillation lead only |
0922T | Removal of a permanent cardiac contractility modulation‑defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only |
0923T | Removal and replacement of permanent cardiac contractility modulation‑defibrillation pulse generator only |
0924T | Repositioning of previously implanted cardiac contractility modulation‑defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sensing and therapeutic parameters |
0925T | Relocation of skin pocket for implanted cardiac contractility modulation‑defibrillation pulse generator |
0926T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation‑defibrillation system |
0927T | Interrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac contractility modulation‑defibrillation system |
0928T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system with interim analysis and report(s) by a physician or other qualified health care professional |
0929T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation‑defibrillation system, remote data acquisition(s), receipt of transmissions, technician review, technical support, and distribution of results |
0930T | Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), at time of initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator |
0931T | Electrophysiologic evaluation of cardiac contractility modulation‑defibrillator leads, including defibrillation‑threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), separate from initial implantation or replacement with testing of cardiac contractility modulation‑defibrillator pulse generator |
0933T | Transcatheter implantation of wireless left atrial pressure sensor for long‑term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation |
0934T | Remote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and trend analysis, with adjustments to the diuretics plan, treatment paradigm thresholds, medications or lifestyle modifications, when performed, and report(s) by a physician or other qualified health care professional |
0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral |
82542 | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase |
83921 | Organic Acid, Single, Quantitative |
93701 | Bioimpedance‑derived physiologic cardiovascular analysis |
A2027 | Matriderm, per square centimeter |
A2028 | Micromatrix flex, per mg |
A2029 | Mirotract wound matrix sheet, per cubic centimeter |
A4543 | Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month |
A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome |
E0738 | Upper extremity rehabilitation system providing active assistance to facilitate muscle re‑education, includes microprocessor, all components and accessories |
J9248 | Injection, melphalan (Hepzato), 1 mg |
L5783 | Addition to lower extremity, user adjustable, mechanical, residual limb volume management system |
L5841 | Addition, endoskeletal knee‑shin system, polycentric, pneumatic swing, and stance phase control |
Not all PA requirements are listed here. Detailed PA requirements are available on https://anthem.com/provider/medicare‑advantage under the Resources tab. Alternatively, contracted providers can access the information at https://Availity.com. Providers may also call Provider Services assistance with PA requirements.
UM AROW A2024M2893
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