Global 3M19 Medical Policy and Technology Assessment Committee prior authorization requirement updates

Category: Medicaid

 

Effective February 1, 2020, prior authorization (PA) requirements will change for the following services. These services will require PA by Anthem Blue Cross and Blue Shield Medicaid for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following codes:

• 43238: esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus
• 43242: esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound)
• 43253: esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s)
• 78608: brain imaging, PET; metabolic evaluation
• 78609: brain imaging, PET; perfusion evaluation
• 81227: Cyp2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (for example, drug metabolism), gene analysis, common variants (for example, *2, *3, *5, *6)
• 0070U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, common and select rare variants (including *2, *3, *4, *4N, *5, *6, *7, *8, *9)
• 0072U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including CYP2D6 to 2D7 hybrid gene)
• 0073U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including CYP2D7 to 2D6 hybrid gene)
• 0074U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including nonduplicated gene)
• 0075U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis (including 5 gene duplication/multiplication)
• 0076U: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (for example, drug metabolism) gene analysis, targeted sequence analysis
• J9036: injection, bendamustine hydrochloride (Belrapzo®), 1 mg
• 81479: unlisted molecular pathology procedure
• 81599: unlisted multianalyte assay with algorithmic analysis
• E2599: accessory for speech generating device, not otherwise classified
• G9143: warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)

 

Request PA via:

• Web: availity.com
• Fax: 1-800-964-3627
• Phone: 1-855-661-2028

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the Provider Self-Service Tool on the Availity Portal by going to https://mediproviders.anthem.com/ky > Login.

 

Contracted and non-contracted providers unable to access Availity can go to https://mediproviders.anthem.com/ky > Precertification or call Provider Services at 1-855-661-2028 for assistance with PA.