Prior authorization requirement changes for multiple medical codes effective September 1, 2021

Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus offered by HealthKeepers, Inc.

 

Effective September 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by HealthKeepers, Inc. for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

 

Utilization Management Authorization Rule Operations Workgroup item 1837 (UM AROW 1837)

 

• 0045U — oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score
• 0153U — oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement
• 0244U — oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue
• 81404 — molecular pathology procedure level 5
• 81414 — cardiac ion channelopathies (for example, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1
• 81439 — hereditary cardiomyopathy (for example, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (for example, DSG2, MYBPC3, MYH7, PKP2, TTN)
• 81518 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes
  (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy
• 81519 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score
• 81520 — oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score
• 81521 — oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed
  paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis
• 81522 — oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes
  (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score
• S3854 — gene expression profiling panel for use in the management of breast cancer treatment
• S3861 — genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and variants for suspected brugada syndrome
• S3865 — comprehensive gene sequence analysis for hypertrophic cardiomyopathy
• S3866 — genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in an individual with a known HCM mutation in the family

 

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

 

• Web: https://providers.anthem.com/va
• Fax: 800-964-3627
• Phone: 800-901-0020

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://providers.anthem.com/va > Login. Contracted and noncontracted providers who are unable to access Availity can call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687 for assistance with PA requirements.

 

*Availity, LLC is an independent company providing administrative support services on behalf of HealthKeepers, Inc.

 

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