Prior authorization update: criteria change for ambulance services and peripheral nerve blocks

Effective for dates of service on and after August 1, 2024, Anthem will utilize the following Anthem Medical Policies and UM Guidelines for ambulance services and peripheral nerve blocks.

Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Water

Includes the following codes:

• A0430 Fixed Wing Air Transport
• A0431 Rotary Wing Air Transport

Medical Policy SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain

Includes the following codes:

• 64415 Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance when performed
• 64417 Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance when performed
• 64447 Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance when performed
• 64450 Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch

Not all prior authorization (PA) requirements are listed here. Detailed PA requirements are available to providers on the provider website at https://providers.anthem.com/kentucky-provider/home. Select the Claims 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.