Policy Updates Prior AuthorizationMedicaid 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