Policy Updates Prior AuthorizationMedicare AdvantageNovember 9, 2023

Prior authorization requirement changes effective March 1, 2024 

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

Effective March 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Empire BlueCross BlueShield for Medicare 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

0239U

Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, ins

0388U

Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct

0392U

Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an

0397U

Oncology (non-small cell lung cancer), cell-free DNA from plasma, targeted sequence analysis of at least 109 genes, including sequence variants, substitutions, insertions, del

0400U

Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie

0401U

Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a

Not all PA requirements are listed here. Detailed PA requirements are available to providers on empireblue.com/medicareprovider or for contracted providers by accessing Availity.com. Providers may also call the number on the back of their patient’s member ID card for Provider Services for assistance with PA requirements.

UM AROW #: A2023M0444

Services provided by Empire HealthChoice HMO, Inc., Empire HealthChoice Assurance, Inc., or Empire BlueCross BlueShield Retiree Solutions. Empire BlueCross BlueShield Retiree Solutions is the trade name of Anthem Insurance Companies, Inc. lndependent licensees of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield plans.

NYBCBS-CR-044226-23-CPN43850, NYBCBS-CR-044227-23-SRS43850

PUBLICATIONS: December 2023 Provider Newsletter