Policy Updates Prior AuthorizationMedicare 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

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