Prior authorization requirements for the below codes

On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements changed 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:

• 15771 — Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
• 15772 — Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
• 15773 — Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
• 15774 — Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
• 31574 — Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral
• 0378T — Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
• 0379T — Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
• C9122 — Mometasone furoate sinus implant, 10 mcg (Sinuva)
• 11950 — Subcutaneous injection of filling material (for example, collagen); 1 cc or less
• 11951 — Subcutaneous injection of filling material (for example, collagen); 1.1 to 5.0 cc
• 11952 — Subcutaneous injection of filling material (for example, collagen); 5.1 to 10.0 cc
• 11954 — Subcutaneous injection of filling material (for example, collagen); over 10.0 cc
• 0565T — Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
• 0566T — Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
• C1878 — Material for vocal cord medialization, synthetic (implantable)
• G0429 — Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (for example, as a result of highly active antiretroviral therapy)
• L8607 — Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
• Q2026 — Injection, Radiesse, 0.1 ml
• Q2028 — Injection, sculptra, 0.5 mg
• 0489T — Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells
• 0490T — Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands
• 0202U — Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
• 17999 — Unlisted procedure, skin, mucous membrane and subcutaneous tissue
• 46999 — Unlisted procedure, anus

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/provider/medicare-advantage > 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-0170-20