Policy Updates Prior AuthorizationHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingSeptember 22, 2023

Prior authorization update

Effective January 1, 2024, the below CPT® codes will require prior authorization. All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The prior authorization (PA) lookup tool allows providers to search codes by the specific line of business (Hoosier Healthwise, Healthy Indiana Plan, or Hoosier Care Connect) to determine if PA is required and which guideline is utilized for the case review. To access the PA lookup tool, go to https://providers.anthem.com/in, and select Precertification Lookup Tool under the Claims drop-down.

Detailed PA requirements are available to contracted providers via the provider self-service tool on Availity Essentials* at Availity.com or go to https://providers.anthem.com/in and select Log in to Availity.

For assistance with questions regarding the PA requirement change, please call Provider Services at one of the phone numbers listed below:

  • Hoosier Healthwise — 866-408-6132
  • Healthy Indiana Plan — 844-533-1995
  • Hoosier Care Connect — 844-284-1798

Clinical Utilization Management Guidelines (CUMG) number

CUMG title

CPT code

MCG: Oncology Companion Diagnostic Testing - Guardant360 CDx (A-1056)

LCD MolDX: Molecular Diagnostic Tests (MDT) (L36807)

NCD Next Generation Sequencing (NGS) (90.2) Version 2 (N902v2)

Guardant360 CDx is a next-generation sequencing assay consisting of a panel of 55 genes that analyzes cell-free DNA from plasma to detect genetic alterations (in other words, single nucleotide variants, insertions and deletions, copy number amplifications, fusions) that may be found in cancer.

0242U

LCD MolDX: Plasma-Based Genomic Profiling in Solid Tumors (L38168) 

LCD MolDX: Molecular Diagnostic Tests (MDT) (L36807) 

Guardant360® from Guardant Health Inc. The test uses a next–generation sequencing (NGS) targeted sequence analysis panel to evaluate cell–free circulating DNA from a blood specimen for 83 or more genes associated with solid–organ neoplasms.

0326U

MCG: Hemoglobin C and E - HBB Gene (A-0604)

MCG: Beta Thalassemia - HBB Gene (A-0815)

MCG: Sickle Cell Disease - HBB Gene (A-0864)

Analyze the entire gene sequence for the hemoglobin, subunit beta (HBB) gene.

81364

MCG: Myeloproliferative Neoplasms - MPL Gene (A-0843)

 

Variants of specific gene sequences of the MPL (MPL proto–oncogene, thrombopoietin receptor) gene, such as W515A, W515K, W515L, W515R, which may be associated with myeloproliferative neoplasms (MPN) such as essential thrombocythemia (ET) in JAK 2 V617F–negative patients.

81338

INBCBS-CD-034217-23

PUBLICATIONS: October 2023 Provider Newsletter