MedicaidNovember 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:
- Web: Log in to https://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 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
To view this article online:
Visit https://providernews.anthem.com/nevada/articles/prior-authorization-requirement-changes-23133
Or scan this QR code with your phone