Anthem Blue Cross and Blue Shield | CommercialJuly 1, 2025
Notice of material change/amendment to contract
Precertification/Prior Authorization list change notification July 1, 2025
The following services will be added to precertification/prior authorization for the effective dates listed below.
Eligibility and benefits can be verified by accessing Availity Essentials at https://Availity.com or by calling the number on the back of the member’s identification card. Precertification/prior authorization is based on the member’s benefit plan/eligibility when the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract’s effective dates. The providers are responsible for the verification of member eligibility and covered benefits.
If the requirements are not met, those services may be deemed ineligible for payment.
Providers may appeal online through Availity Essentials (https://Availity.com) or contact Provider Services via the number on the back of our member ID card with additional information, which may include medical records.
Add to precertification/prior authorization:
Criteria | Criteria description | Code | Effective date |
LAB.00035 | Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis | 0521U | 10/01/25 |
LAB.00040 | Serum Biomarker Tests for Risk of Preeclampsia | 0524U | 10/01/25 |
LAB.00003 | In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays | 0525U | 10/01/25 |
SURG.00165 | Histotripsy | 0686T | 10/01/25 |
SURG.00165 | Histotripsy | 0888T | 10/01/25 |
SURG.00135 | Renal Sympathetic Nerve Ablation | 0935T | 10/01/25 |
CG-SURG-127 | Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses | 15011 | 10/01/25 |
CG-SURG-127 | Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses | 15013 | 10/01/25 |
CG-SURG-127 | Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses | 15015 | 10/01/25 |
CG-SURG-127 | Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses | 15017 | 10/01/25 |
MED.00057 | MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications | 61715 | 10/01/25 |
SURG.00156 | Implanted Artificial Iris Devices | 66683 | 10/01/25 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 82233 | 10/01/25 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 82234 | 10/01/25 |
LAB.00028, LAB.00046 | Blood-based Biomarker Tests for Multiple Sclerosis | 83884 | 10/01/25 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 84393 | 10/01/25 |
LAB.00046 | Testing for Biochemical Markers for Alzheimer's Disease | 84394 | 10/01/25 |
SURG.00135 | Renal Sympathetic Nerve Ablation | C1735 | 10/01/25 |
SURG.00135 | Renal Sympathetic Nerve Ablation | C1736 | 10/01/25 |
CG-SURG-127 | Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses | C8002 | 10/01/25 |
SURG.00162 | Implantable Shock Absorber for Treatment of Knee Osteoarthritis | C8003 | 10/01/25 |
SURG.00158 | Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain | C9807 | 10/01/25 |
SURG.00155 | Cryosurgery of Peripheral Nerves | C9808 | 10/01/25 |
SURG.00155 | Cryosurgery of Peripheral Nerves | C9809 | 10/01/25 |
DME.00053 | Home Video-Assisted Robotic Rehabilitation Systems | E0739 | 10/01/25 |
MED.00152 | Outpatient Intravenous Insulin Therapy | G9147 | 10/01/25 |
MED.00135 | Gene Therapy for Hemophilia | J1414 | 10/01/25 |
MED.00140, | Gene Therapy for Beta Thalassemia | J3392 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4346 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4347 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4348 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4349 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4350 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4351 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4352 | 10/01/25 |
SURG.00011 | Products for Wound Healing and Soft Tissue Grafting: Investigational | Q4353 | 10/01/25 |
UM AROW A2025M3614
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MULTI-BCBS-CM-085058-25
PUBLICATIONS: July 2025 Provider Newsletter
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