Medicare AdvantageAugust 1, 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 BMA for Medicare Advantage 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 |
0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single-nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma |
0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate Guardant360 Response™, Guardant Health, Inc, Guardant Health, Inc |
0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition Genomind® Pharmacogenetics Report – Full, Genomind®, Inc, Genomind®, Inc |
0428U | Oncology (breast), targeted hybrid-capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden Epic Sciences ctDNA Metastatic Breast Cancer Panel, Epic Sciences, Inc, Epic Sciences, Inc |
0430U | Gastroenterology, malabsorption evaluation of alpha-1-antitrypsin, calprotectin, pancreatic elastase and reducing substances, feces, quantitative Malabsorption Evaluation Panel, Mayo Clinic/Mayo Clinic Laboratories, Mayo Clinic/Mayo Clinic Laboratories |
0435U | Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotoxicity percentage observed, minimum of 14 drugs or drug combinations ChemoID®, ChemoID® Lab, Cordgenics, LLC |
0790T | Revision (eg, augmentation, division of tether), replacement, or removal of thoracolumbar or lumbar vertebral body tethering, including thoracoscopy, when performed |
0810T | Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies |
0815T | Ultrasound-based radiofrequency echographic multi-spectrometry (REMS), bone-density study and fracture-risk assessment, 1 or more sites, hips, pelvis, or spine |
0823T | Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography |
0824T | Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography), when performed |
0825T | Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (eg, interrogation or programming), when performed |
0826T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional, leadless pacemaker system in single-cardiac chamber |
0861T | Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; both components (battery and transmitter) |
0862T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only |
0863T | Relocation of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; transmitter component only |
0864T | Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy |
22836 | Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; up to 7 vertebral segments |
22837 | Anterior thoracic vertebral body tethering, including thoracoscopy, when performed; 8 or more vertebral segments |
22838 | Revision (eg, augmentation, division of tether), replacement, or removal of thoracic vertebral body tethering, including thoracoscopy, when performed |
31242 | Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve |
31243 | Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve |
33276 | Insertion of phrenic nerve stimulator system (pulse generator and stimulating lead[s]), including vessel catheterization, all imaging guidance, and pulse generator initial analysis with diagnostic mode activation, when performed |
33279 | Removal of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) only |
33281 | Repositioning of phrenic nerve stimulator transvenous lead(s) |
33287 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; pulse generator |
33288 | Removal and replacement of phrenic nerve stimulator, including vessel catheterization, all imaging guidance, and interrogation and programming, when performed; transvenous stimulation or sensing lead(s) |
37242 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) [when specified as genicular artery embolization] |
81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years Enhanced Liver Fibrosis™ (ELF™) Test, Siemens Healthcare Diagnostics Inc/Siemens Healthcare Laboratory LLC |
93150 | Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming |
93151 | Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system |
93152 | Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography |
93153 | Interrogation without programming of implanted phrenic nerve stimulator system |
E0746 | Electromyograph Biofeedback |
L5615 | Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control |
Q4279 | Vendaje ac, per square centimeter |
Q4287 | Dermabind dl, per square centimeter |
Q4288 | Dermabind ch, per square centimeter |
Q4289 | Revoshield + amniotic barrier, per square centimeter |
Q4290 | Membrane Wrap-Hydro TM, per sq cm |
Q4291 | Lamellas xt, per square centimeter |
Q4292 | Lamellas, per square centimeter |
Q4293 | Acesso dl, per square centimeter |
Q4294 | Amnio quad-core, per square centimeter |
Q4295 | Amnio tri-core amniotic, per square centimeter |
Q4296 | Rebound matrix, per square centimeter |
Q4297 | Emerge matrix, per square centimeter |
Q4298 | Amnicore pro, per square centimeter |
Q4299 | Amnicore pro+, per square centimeter |
Q4300 | Acesso tl, per square centimeter |
Q4301 | Activate matrix, per square centimeter |
Q4302 | Complete aca, per square centimeter |
Q4303 | Complete aa, per square centimeter |
Q4304 | Grafix plus, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on provider.bluemedadv.com on the Resources tab or for contracted providers by accessing Availity.com.
UM AROW A2024M1469
Blue Medicare Advantage is the trade name of Group Retiree Health Solutions, Inc., an independent licensee of the Blue Cross Blue Shield Association.
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