Medicare AdvantageSeptember 23, 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 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. 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 ePlex® BCID Gram-Positive Panel, GenMark Diagnostics, Inc, GenMark Diagnostics, Inc |
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 ePlex® BCID Gram-Negative Panel, GenMark Diagnostics, Inc, GenMark Diagnostics, Inc |
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 Bridge Urinary Tract Infection Detection and Resistance Test, Bridge Diagnostics |
0369U | Infectious agent detection by nucleic acid (DNA and RNA), gastrointestinal pathogens, 31 bacterial, viral, and parasitic organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique |
0370U | GI assay (Gastrointestinal Pathogen with ABR), Lab Genomics LLC, Thermo Fisher Scientific |
0373U | Infectious agent detection by nucleic acid (DNA and RNA), respiratory tract infection, 17 bacteria, 8 fungus, 13 virus, and 16 antibiotic-resistance genes, multiplex amplified probe technique, upper or lower respiratory specimen |
0445U | β-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology |
0524T | Elecsys® PhosphoTau (181P) CSF (pTau181) and βAmyloid (1-42) CSF II (Abeta 42) Ratio, Roche Diagnostics Operations, Inc (US owner/operator) |
21086 | Impression & Custom Preparation; Auricular Prosthesis |
36473 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated |
36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated |
64568 | Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator |
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 (e.g., porcine small intestine submucosa [SIS]) |
C9797 | Vascular embolization or occlusion procedure with use of a pressure-generating catheter (e.g., 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 |
L5991 | Addition to lower extremity prostheses, osseointegrated external prosthetic connector |
L8045 | Auricular Prosthesis |
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 |
S9002 | Intravaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://anthem.com/provider/medicare-advantage on the Resources tab or for contracted providers by accessing Availity.com.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Independent licensees 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
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