Guideline Updates Prior AuthorizationAnthem Blue Cross and Blue Shield | Medicare AdvantageSeptember 23, 2024

Prior authorization requirement changes

Effective January 1, 2025

Effective January 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 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

0141U

Infectious disease (bacteria and fungi), gram-positive organism identification and drug resistance element detection, DNA (20 gram-positive bacterial targets, 4 resistance genes, 1 pan gram-negative bacterial target, 1 pan Candida target), blood culture, amplified probe technique, each target reported as detected or not detected ePlex® BCID Gram-Positive Panel, GenMark Diagnostics, Inc, GenMark Diagnostics, Inc

0142U

Infectious disease (bacteria and fungi), gram-negative bacterial identification and drug resistance element detection, DNA (21 gram-negative bacterial targets, 6 resistance genes, 1 pan gram-positive bacterial target, 1 pan Candida target), amplified probe technique, each target reported as detected or not detected ePlex® BCID Gram-Negative Panel, GenMark Diagnostics, Inc, GenMark Diagnostics, Inc

0321U

Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique Bridge Urinary Tract Infection Detection and Resistance Test, Bridge Diagnostics

0369U

Infectious agent detection by nucleic acid (DNA and RNA), gastrointestinal pathogens, 31 bacterial, viral, and parasitic organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique

0370U

GI assay (Gastrointestinal Pathogen with ABR), Lab Genomics LLC, Thermo Fisher Scientific

0373U

Infectious agent detection by nucleic acid (DNA and RNA), respiratory tract infection, 17 bacteria, 8 fungus, 13 virus, and 16 antibiotic-resistance genes, multiplex amplified probe technique, upper or lower respiratory specimen

0445U

β-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology

0524T

Elecsys® PhosphoTau (181P) CSF (pTau181) and βAmyloid (1-42) CSF II (Abeta 42) Ratio, Roche Diagnostics Operations, Inc (US owner/operator)

21086

Impression & Custom Preparation; Auricular Prosthesis

36473

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated

36482

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated

64568

Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator

A2026

Restrata MiniMatrix, 5 mg

A4438

Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each

C1734

Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)

C9796

Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [SIS])

C9797

Vascular embolization or occlusion procedure with use of a pressure-generating catheter (e.g., one-way valve, intermittently occluding), inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction

L5991

Addition to lower extremity prostheses, osseointegrated external prosthetic connector

L8045

Auricular Prosthesis

Q4305

American Amnion AC Tri-Layer, per sq cm

Q4306

American Amnion AC, per sq cm

Q4307

American Amnion, per sq cm

Q4308

Sanopellis, per sq cm

Q4309

VIA Matrix, per sq cm

S9002

Intravaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device

Not all PA requirements are listed here. Detailed PA requirements are available to providers on https://anthem.com/provider/medicare-advantage on the Resources tab or for contracted providers by accessing Availity.com.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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PUBLICATIONS: October 2024 Provider Newsletter