Medicare AdvantageSeptember 24, 2024
Prior authorization requirement changes
Effective February 1, 2025
Effective February 1, 2025, 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 | Code description |
0456U | Autoimmune (rheumatoid arthritis), next-generation sequencing (NGS), gene expression testing of 19 genes, whole blood, with analysis of anti-cyclic citrullinated peptides (CCP) levels, combined with sex, patient global assessment, and body mass index (BMI), algorithm reported as a score that predicts nonresponse to tumor necrosis factor inhibitor (TNFi) therapy |
0459U | β-amyloid (Abeta42) and total tau (tTau), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology |
0468U | Hepatology (nonalcoholic steatohepatitis [NASH]), miR-34a5p, alpha 2-macroglobulin, YKL40, HbA1c, serum and whole blood, algorithm reported as a single score for NASH activity and fibrosis |
J0687 | Injection, cefazolin sodium (WG Critical Care), not therapeutically equivalent to J0690, 500 mg |
J0688 | Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg |
J0689 | Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg |
J0744 | Injection, ciprofloxacin for intravenous infusion, 200 mg |
J2183 | Injection, meropenem (WG Critical Care), not therapeutically equivalent to J2185, 100 mg |
J2184 | Injection, meropenem (B. Braun), not therapeutically equivalent to J2185, 100 mg |
J2281 | Injection, moxifloxacin (Fresenius Kabi), not therapeutically equivalent to J2280, 100 mg |
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. Providers may also call Provider Services at the number on the back of the patient’s member ID card for assistance with PA requirements.
UM AROW #: A2024M2186
Blue Medicare Advantage is the trade name of Group Retiree Health Solutions, Inc., an independent licensee of the Blue Cross Blue Shield Association.
PAIBC-CR-068213-24-CPN67511
To view this article online:
Visit https://providernews.anthem.com/pennsylvania/articles/prior-authorization-requirement-changes-22073
Or scan this QR code with your phone