Policy Updates Prior AuthorizationMedicaidMay 31, 2023

Carelon Medical Benefits Management, Inc. Genetic Testing CPT Code List update

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Effective for dates of service on and after July 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.*

CPT® code

Description

81335

TPMT (thiopurine S-methyltransferase) (such as drug metabolism), gene analysis, common variants (such as *2, *3).

81405

Molecular pathology procedure, Level 6 (such as analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) ABCD1

(ATP-binding cassette, sub-family D [ALD], member 1)

(such as adrenoleukodystrophy) etc.

81403

Molecular Pathology procedure level 4

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of several ways:

  • Access the ProviderPortalSM directly via www.providerportal.com:
    • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
  • You may access and download a copy of the current and upcoming guidelines here.

The Prior Authorization Lookup Tool allows providers to search codes by the specific line of business to determine if prior authorization (PA) is required and which guideline is utilized for the case review. The Prior Authorization Lookup Tool is available at https://providers.anthem.com/in > Claims > Precertification lookup tool.

What if I need assistance?
If you have questions about this communication or need assistance with any other item, contact your Provider Relationship Account Manager associate or call Provider Services at 800-450-8573.

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

NYBCBS-CD-017603-23-CPN17426

PUBLICATIONS: June 2023 Provider Newsletter