Prior authorization requirement changes

Effective June 1, 2025, precertification/prior authorization requirements will change for the following code(s). The medical code(s) listed below will require precertification/prior authorization by Anthem for Medicaid 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/prior authorization rules and must be considered first when determining coverage. If the requirements are not met, those services may be deemed ineligible for payment. Providers may appeal online through Availity Essentials or by phone by calling Provider Services with additional information which may include medical records.

Prior authorization requirements will be added for the following code(s):

• J9248 — Injection, melphalan (Hepzato), 1 mg
• L5841 — Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control

To request precertification/prior authorization, you may use one of the following methods:

• Web: Once logged in to Availity Essentials at https://Availity.com.
• Fax: 800-964-3627
• Phone: 855-558-1443

Not all precertification/prior authorization requirements are listed here. Detailed precertification/prior authorization requirements are available to providers on https://providers.anthem.com/wisconsin-provider/claims/precertification-requirements or for contracted providers by accessing https://Availity.com. Providers may also call Provider Services at 855‑558‑1443 for assistance with precertification/prior authorization requirements.