Medicaid Managed CareOctober 9, 2024
Prior authorization requirement changes
Effective December 1, 2024
Effective December 1, 2024, 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 is required if the request is for gender-affirming care services, including but not limited to diagnoses codes F64.0, F64.1, F64.2, F64.8, F64.9, or Z87.890. Ohio law prohibits Medicaid coverage of inpatient and outpatient hospital services relating to gender transformation.
Code | Description |
11401 | Excise, Benign Skin Lesion, Incl Margins, Except Skin Tag, Trunk/Arms/Legs; Excised Diam 0.6-1.0 Cm |
11406 | Excise, Benign Skin Lesion, Incl Margins, Except Skin Tag, Trunk/Arms/Legs; Excised Diam > 4.0 Cm |
11420 | Excise Benign Skin Lesion W/Marg, Excpt Skin Tag Scalp/Neck/Hands/Feet/Genital; Excise Diam 0.5cm/< |
12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less |
13121 | Repair, Complex, Scalp, Arms, &/Or Legs; 2.6 To 7.5 Cm |
13122 | Repair, Complex, Scalp/Arms/Legs; Add'l 5.0 Cm/< |
14060 | Adjacent Tissue Transfer/Rearrangement, Eyelids/Nose/Ears/Lips; Defect 10 Sq Cm/< |
15002 | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children |
15115 | Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children |
15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less |
15151 | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) |
15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less |
15156 | Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children |
15770 | Graft; Derma-Fat-Fascia |
20902 | Bone graft, any donor area; major or large |
20912 | Cartilage graft; nasal septum |
21085 | Impression & Custom Preparation; Oral Surgical Splint |
21555 | Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm |
31579 | Laryngoscopy, flexible or rigid telescopic, with stroboscopy |
51610 | Injection Proc, Retrograde Urethrocystography |
51703 | Insertion, Temporary Indwelling Bladder Catheter; Complicated |
52000 | Cystourethroscopy (Sep Proc) |
52281 | Cystourethroscopy, W/Calibration &/Or Dilation, Urethral Stricture/Stenosis, Male/Female |
53010 | Urethrotomy/Urethrostomy, Ext (Sep Proc); Perineal Urethra, Ext |
53400 | Urethroplasty; 1st Stage, Fistula/Diverticulum/Stricture |
53405 | Urethroplasty; 2nd Stage (Formation, Urethra), W/Urinary Diversion |
55120 | Removal, Fb In Scrotum |
64874 | Suture, Nerve; W/Extensive Mobilization/Transposition, Nerve |
67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) |
67903 | Repair, Blepharoptosis; (Tarso) Levator Resection/Advancement, Int Approach |
67904 | Repair, Blepharoptosis; (Tarso) Levator Resection/Advancement, Ext Approach |
67906 | Repair, Blepharoptosis; Superior Rectus W/Fascial Sling |
67908 | Repair, Blepharoptosis; Conjunctivo-Tarso-Muller's Muscle-Levator Resection |
67923 | Repair, Entropion; Blepharoplasty, Excision Tarsal Wedge |
67924 | Repair, Entropion; Blepharoplasty, Extensive |
97606 | Negative Pressure Wound Therapy, Per Session; Total Area > 50 Sq Cm |
99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. |
C5272 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) |
C5274 | Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) |
C5276 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) |
C5277 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children |
C5278 | Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) |
Q4116 | Alloderm, per square centimeter |
Q4176 | Neopatch or Therion, per sq cm |
To request PA, you may use one of the following methods:
- Web: once logged in to Availity Essentials at Availity.com
- Fax:
- 877-643-0672 for Physical Health
- 866-577-2183 for Behavioral Health
- Phone: 800-601-9935
Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://providers.anthem.com/oh on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 844-912-1226 for assistance with PA requirements.
UM AROW A2024M2246
Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company. Independent licensee(s) of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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PUBLICATIONS: November 2024 Provider Newsletter
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