Policy Updates Prior AuthorizationMedicaidNovember 21, 2024

Prior authorization requirement changes

Effective January 1, 2025

Effective January 1, 2025, 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

0141U

Infectious disease (bacteria and fungi), gram-positive organism identification and drug resistance element detection, DNA (20 gram-positive bacterial targets, 4 resistance genes, 1 pan gram-negative bacterial target, 1 pan Candida target), blood culture, amplified probe technique, each target reported as detected or not detected

0142U

Infectious disease (bacteria and fungi), gram-negative bacterial identification and drug resistance element detection, DNA (21 gram-negative bacterial targets, 6 resistance genes, 1 pan gram-positive bacterial target, 1 pan Candida target), amplified probe technique, each target reported as detected or not detected

0321U

Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique

0449T

Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device

21086

Impression & Custom Preparation; Auricular Prosthesis

36468

Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk

36473

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated

37241

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (for example, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

61885

Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Sngle Electrod Array

64568

Open implantation of cranial nerve (for example, vagus nerve) neurostimulator electrode array and pulse generator

64569

Revision or replacement of cranial nerve (for example, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator

66183

Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach

66989

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (for example, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (for example, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more

66991

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification); with insertion of intraocular (for example, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more

82107

Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio)

86304

Immunoassay, Tumor Antigen, Quantitative; Ca 125

95976

Electronic analysis of implanted neurostimulator pulse generator/transmitter (for example, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional

95977

Electronic analysis of implanted neurostimulator pulse generator/transmitter (for example, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional

97760

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes

97763

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

A2026

Restrata MiniMatrix, 5 mg

A4438

Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each

C1734

Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)

C9796

Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (for example, porcine small intestine submucosa [SIS])

C9797

Vascular embolization or occlusion procedure with use of a pressure-generating catheter (for example, one-way valve, intermittently occluding), inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction

E0735

Non-invasive vagus nerve stimulator

E2298

Complex rehabilitative power wheelchair accessory, power seat elevation system, any type

Q4305

American Amnion AC Tri-Layer, per sq cm

Q4306

American Amnion AC, per sq cm

Q4307

American Amnion, per sq cm

Q4308

Sanopellis, per sq cm

Q4309

VIA Matrix, per sq cm

Q4310

Procenta, per 100 mg

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

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

UM AROW #: A2024M187

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.

NVBCBS-CD-065600-24-CPN65118