Policy Updates Prior AuthorizationMedicaid Managed CareMarch 26, 2025

Prior authorization requirement changes

Effective May 1, 2025, 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.

If the requirements are not met, those services may be deemed ineligible for payment.

Providers may appeal online through Availity Essentials or by calling 844‑912‑1226 with additional information, which may include medical records.

Prior authorization requirements will be added for the following code(s):

Code

Description

0627T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level

0629T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level

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

15271

Application Of Skin Substitute Graft to Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm or Less Wound Surface Area

15273

Application Of Skin Substitute Graft to Trunk, Arms, Legs, 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

15275

Application Of 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; first 25 sq cm or less wound surface area

15277

Application Of 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

C5271

Application of low-cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

C5273

Application of low-cost skin substitute graft to trunk, arms, legs, 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

C5275

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; first 25 sq cm or less wound surface area

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

Q4101

Apligraf, per square centimeter

Q4106

Dermagraft, per square centimeter

To request PA, you may use one of the following methods:

  • Web: once logged in to Availity Essentials at https://Availity.com
  • Fax:
    • Physical health: 877‑643‑0672
    • Behavioral health: 866‑577‑2183
  • Phone: 800‑601‑9935

Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://providers.anthem.com/oh on the Resources tab or for contracted providers by accessing Availity Essentials at https://Availity.com. Providers may also call 844‑912‑1226 for assistance with PA requirements.

UM AROW A2025M2993

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.

OHBCBS-CD-077341-25

PUBLICATIONS: April 2025 Provider Newsletter