Policy Updates Prior AuthorizationMedicaidSeptember 19, 2024

Prior authorization requirement changes

Effective November 1, 2024

Effective November 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid 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 PA rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

Code

Description

31242

Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve

31243

Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve

33276

Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic move activation, when performed

33277

Insertion of phrenic nerve stimulator transvenous sensing lead (List separately in addition to code for primary procedure)

61889

Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy, when performed, with direct or inductive coupling, with connection to depth and/or cortical strip electrode array(s)

61891

Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode array(s)

64596

Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array

64597

Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array

J1412

Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes

J1413

Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose

L5615

Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control

L5926

Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type

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

  • Web: once logged in to Availity Essentials at Availity.com
  • Fax: 800-964-3627
  • Phone: 844-396-2330

Not all PA requirements are listed here. Detailed PA requirements are available to providers on providers.anthem.com/nv on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-396-2330 for assistance with PA requirements.

UM AROW A2024M1495

Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: October 2024 Provider Newsletter