Policy Updates Prior AuthorizationMedicaidJuly 5, 2023

Prior Authorization requirement changes effective September 1, 2023

Effective September 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 for 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):

81170

ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (for example, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain

81324

PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis

81325

PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis

81326

PMP22 (peripheral myelin protein 22) (for example, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant

81414

Cardiac ion channelopathies (for example, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 (when specified as testing for 4 or less genes, including KCNH2 and KCNQ1 [and SCN5A if performed] for LTQS only)

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

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

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

UM AROW #4073

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

KYBCBS-CD-021098-23-CPN20084

PUBLICATIONS: August 2023 Provider Newsletter