Policy Updates Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingFebruary 28, 2025

Frenectomy prior authorization update

Effective April 1, 2025, the below CPT® codes will require preapproval. All covered services are contingent upon medical necessity and benefit coverage at the time of service.

You can use the precertification lookup tool to search codes by the specific line of business to determine whether preapproval is required, and which guideline is used for the case review. To access the precertification lookup tool, visit providers.anthem.com/indiana‑provider/claims/prior‑authorization-requirements/precertification‑lookup.

Detailed preapproval requirements are available via the provider self-service tool on Availity Essentials, or you can visit https://providers.anthem.com/in and select Launch Availity.

If you have questions regarding these changes, contact Provider Services at 866‑408-6132 (Hoosier Healthwise), 844‑533-1995 (Healthy Indiana Plan), 844‑284-1798 (Hoosier Care Connect), or 833‑569-4739 (Indiana PathWays for Aging).

Guideline link

CPT code description

CPT code

BT2024177 Frenectomy Prior Authorization Criteria

Incision, Labial Frenum (Frenectomy)

40806

BT2024177 Frenectomy PA Criteria

Excision, Frenum, Labial/Buccal (Frenumectomy, Frenulectomy, Frenectomy)

40819

BT2024177 Frenectomy PA Criteria

Incision, Lingual Frenum (Frenotomy)

41010

BT2024177 Frenectomy PA Criteria

Excision, Lingual Frenum (Frenectomy)

41115

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

Providers who are contracted with Anthem Blue Cross and Blue Shield to serve Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for Aging through an accountable care organization (ACO), participating medical group (PMG) or Independent Physician Association (IPA) are to follow guidelines and practices of the group. This includes but is not limited to authorization, covered benefits and services, and claims submittal. If you have questions, please contact your group administrator or your Anthem network representative.

INBCBS-CD-074868-24