Policy Updates Medical Policy & Clinical GuidelinesHoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and IN PathWays for AgingDecember 2, 2024

Prior authorization update

Effective January 1, 2025, the CPT® codes below will require prior authorization (PA). All covered services are contingent upon medical necessity and benefit coverage at the time of service.

The PA lookup tool allows providers to search codes by the specific line of business (Medicaid,/SCHIP/Family Care, Hoosier Care Connect, or Indiana PathWays for Aging) to determine if PA is required and which guideline is utilized for the case review. To access the PA lookup tool, go to providers.anthem.com/in, and select PA lookup tool under the Claims drop-down.

Contracted providers can also access the provider lookup tool via Availity Essentials at Availity.com. Select the Payer Spaces, then select the PA lookup tool tile.

For assistance with questions regarding the prior authorization 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
  • Indiana PathWays for Aging — 833-569-4739

CPT code
Description

19316

Mastopexy

19342

Delayed insertion, breast prosthesis following mastopexy, mastectomy/in reconstruction

19350

Nipple/areola reconstruction

19357

Breast reconstruction with tissue expander, immediate and/or delayed, with subseq expansion

21139

Reduction forehead; contouring and setback, anterior frontal sinus wall

21196

Reconstruction, mandibular rami and/or body, sagittal split; with internal rigid fixation

30420

Rhinoplasty, primary; with major septal repair

36466

Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (for example, great saphenous vein, accessory saphenous vein), same leg

37243

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road-mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction

67900

Repair, brow ptosis, (supraciliary/mid-forehead/coronal approach)

61885

SubQ placement cranial neurostimulator pulse generator/receiver; with connection single electrode array

64568

Incision for implantation of cranial nerve (for example, vagus nerve) neurostimulator electrode array and pulse generator

64575

Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

64581

Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement)

64590

Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling

93580

Perc transcatheter closure, congenital interatrial communication with implant

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-069106-24