Wisconsin
Provider Communications
Prior authorization requirement changes effective September 1, 2021 - UM AROW 1837
PA requirements will be added to the following:
- 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
- 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
To request PA, you may use one of the following methods:
- Web: mediproviders.anthem.com/wi
- Fax: 800-964-3627
- Phone: 855-558-1443
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 availity.com or on the provider website at mediproviders.anthem.com/wi > Login. Contracted and non-contracted providers who are unable to access Availity can call our Provider Services at 855-558-1443 for assistance with PA requirements.
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July 2021 Anthem Provider News - Wisconsin