Policy Updates Prior AuthorizationMedicare AdvantageAugust 14, 2025

Precertification/prior authorization requirement changes

Effective December 1, 2025, precertification/prior authorization requirements will change for the following code(s). The medical code(s) listed below will require precertification/prior authorization by Anthem for Medicare Advantage 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 precertification rules and must be considered first when determining coverage.

If the requirements are not met, those services may be deemed ineligible for payment.

Providers may appeal online through Availity Essentials or by phone by calling the phone number on the back of the member ID card with additional information, which may include medical records.

Precertification/prior authorization requirements will be added for the following code(s):

Code

Description

0440T

Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve

0441T

Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve

0442T

Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (such as brachial plexus, pudendal nerve)

0531U

Infectious disease (acid-fast bacteria and invasive fungi), DNA (673 organisms), next-generation sequencing, plasma

0535U

Perfluoroalkyl substances (PFAS) (such as perfluorooctanoic acid, perfluorooctane sulfonic acid), by liquid chromatography with tandem mass spectrometry (LC-MS/MS), plasma or serum, quantitative PFAS Testing & PFASure®FT, National Medical Services (NMS Labs), Laboratory Developed Test

0547U

Neurofilament light chain (NfL), chemiluminescent enzyme immunoassay, plasma, quantitative

0550U

Oncology (prostate), enzyme-linked immunosorbent assays (ELISA) for total prostate-specific antigen (PSA) and free PSA, serum, combined with age, previous negative prostate biopsy status, digital rectal examination findings, prostate volume, and image and data reporting of the prostate, algorithm reported as a risk score for the presence of high-grade prostate cancer ClarityDx Prostate, Protean BioDiagnostics, Protean BioDiagnostics

0551U

Tau, phosphorylated, pTau217, by single-molecule array (ultrasensitive digital protein detection), using plasma

0744T

Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound imaging guidance, when performed, including autogenous or nonautogenous patch graft (such as polyester, ePTFE, bovine pericardium), when performed [VenoValve procedure]

A2030

Miro3D fibers, per mg

A2031

MiroDry Wound Matrix, per sq cm

A2032

Myriad Matrix, per sq cm

A2033

Myriad Morcells, 4 mg

A2034

Foundation DRS Solo, per sq cm

A2035

Corplex P or Theracor P or Allacor P, per mg

A4100

Skin substitute, FDA-cleared as a device, not otherwise specified

A4545

Supplies and accessories for external tibial nerve stimulator (such as socks, gel pads, electrodes), needed for one month

C1763

Connective tissue, nonhuman (includes synthetic)

E0736

Transcutaneous tibial nerve stimulator

L5827

Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping

Not all precertification/prior authorization requirements are listed here. Detailed precertification/prior authorization requirements are available to providers on https://www.anthem.com/nv/provider or for contracted providers by accessing https://Availity.com. Providers may also call for assistance with precertification/prior authorization requirements.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

CPN88807, NVBCBS-CR-089337-25