Policy Updates Prior AuthorizationMedicaidMay 22, 2023

Prior Authorization Requirement Changes Effective June 1, 2023

Prior authorization requirement changes

Effective July 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem Blue Cross and Blue Shield Medicaid (Anthem) for Anthem Blue Cross and Blue Shield Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Code

Description

81309

PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (for example, colorectal and breast cancer) gene analysis, targeted sequence analysis (for example, exons 7,9,20)

81347

SF3B1 (splicing factor [3b] subunit B1) (for example, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (for example, A672T, E622D, L833F, R625C, R625L)

81348

SRSF2 (serine and arginine-rich splicing factor 2) (for example, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (for example, P95H, P95L)

81357

U2AF1 (U2 small nuclear RNA auxiliary factor 1) (for example, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (for example, S34F, S34Y, Q157R, Q157P)

81360

ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (for example, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (for example, E65fs, E122fs, R448fs)

0117U

Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid),LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain

FoundationPI℠,Ethos Laboratories

0040U

BCR/ABL1(t(9;22)) (for example, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative

0049U

NPM1 (nucleophosmin) (for example, acute myeloid leukemia) gene analysis, quantitative

To request PA, you may use one of the following methods:

  • Web: Once logged into Availity Essentials* at http://availity.com.
  • Fax: 800-964-3627
  • Phone: 855-661-2028

Not all PA requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://providers.anthem.com/kentucky-provider/communications/news-and-announcements > Log in on the Resources tab or for contracted providers by accessing http://availity.com. Providers may also call Provider Services at 855-661-2028 for assistance with PA requirements.

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
UM AROW 3959

KYBCBS-CD-018032-23-SRS17359

PUBLICATIONS: June 2023 Provider Newsletter