Medicaid

Effective September 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield Healthcare Solutions for Nevada Medicaid members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.


Noncompliance with new requirements may result in denied claims.


PA requirements will be added to the following:

  • 0153U — oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement
  • 0244U — oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue
  • 81518 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes
    (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy
  • 81519 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score
  • 81522 — oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes
    (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score

 

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

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at availity.com or on the provider website at providers.anthem.com/nv > Login. Contracted and noncontracted providers who are unable to access Availity can call our Provider Services at 844-396-2330 for assistance with PA requirements.

 

ANV-NU-0239-21



Featured In:
July 2021 Anthem Provider News - Nevada