Policy Updates Prior AuthorizationCommercialSeptember 1, 2023

Precertification list change notification for September 2023

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

This article has been updated to remove archived criteria CG-SURG-27. Please see updated article here.

The following services will be added to precertification for the effective dates listed below.

To obtain precertification, providers can access Availity Essentials* (Availity.com) or call Empire BlueCross BlueShield’s Utilization Management department using the number on the back of the member’s identification card. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved. 

Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.

Add to precertification

Criteria

Criteria description

Code

Effective date

CG-SURG-27

Gender Affirming Surgery

15769

12/01/2023 

CG-SURG-88

Mastectomy for Gynecomastia

19300

12/01/2023

CG-SURG-27

Gender Affirming Surgery

19303

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53410

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53420

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53425

12/01/2023

CG-SURG-27

Gender Affirming Surgery

53430

12/01/2023

CG-SURG-27

Gender Affirming Surgery

54400

12/01/2023

CG-SURG-27

Gender Affirming Surgery

57426

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58150

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58571

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58572

12/01/2023

CG-SURG-27

Gender Affirming Surgery

58573

12/01/2023

CG-SURG-27

Gender Affirming Surgery

C1813

12/01/2023

CG-SURG-09

Temporomandibular Disorders

D7899

12/01/2023

CG-SURG-09

Temporomandibular Disorders

D9950

12/01/2023

CG-SURG-09

Temporomandibular Disorders

D9951

12/01/2023

CG-SURG-09

Temporomandibular Disorders

D9952

12/01/2023

CG-DME-45

Ultrasound Bone Growth Stimulation

E0760

12/01/2023

CG-DME-06

Compression Devices for Lymphedema

K1024

12/01/2023

CG-DME-06

Compression Devices for Lymphedema

K1025

12/01/2023

* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.
UM AROW #4605

Commercial services provided by Anthem Blue Cross and Blue Shield, trade name of Anthem HealthChoice HMO, Inc. and Anthem HealthChoice Assurance, Inc., or Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

NYBCBS-CM-034405-23-SRS33553

PUBLICATIONS: September 2023 Provider Newsletter