Policy Updates Prior AuthorizationAnthem 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
Testing for Biochemical Markers for Alzheimer's Disease

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

Previously Titled: Cryoneurolysis

C9808

10/01/25

SURG.00155

Cryosurgery of Peripheral Nerves

Previously titled: Cryoneurolysis

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,
MED.00146

Gene Therapy for Beta Thalassemia
Gene Therapy for Sickle Cell Disease

J3392

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4346

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4347

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4348

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4349

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4350

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4351

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4352

10/01/25

SURG.00011

Products for Wound Healing and Soft Tissue Grafting: Investigational

Previously titled: Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

Q4353

10/01/25

UM AROW A2025M3614

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PUBLICATIONS: July 2025 Provider Newsletter