Prior authorization requirement changes effective September 1, 2021

Effective September 1, 2021, prior authorization (PA) requirements will change for the following codes. The medical codes listed below will require PA by Anthem Blue Cross and Blue Shield for BadgerCare Plus 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:

• 0203U — Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness
• 0208U — Oncology (medullary thyroid carcinoma), mRNA, gene expression analysis of 108 genes, utilizing fine needle aspirate, algorithm reported as positive or negative for medullary thyroid carcinoma
• 0230U — Androgen receptor (AR) (for example, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0231U — Calcium voltage-gated channel subunit alpha 1A (CACNA1A) (for example, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR gene expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0232U — Cystatin B (CSTB) (for example, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0233U — Frataxin (FXN) (for example, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR expansions, mobile element insertions, and variants in non-uniquely mappable regions
• 0234U — Methyl CpG binding protein 2 (MECP2) (for example, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
• 0235U — Phosphatase and tensin homolog (PTEN) (for example, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
• 0236U — Survival of motor neuron 1, telomeric (SMN1) and survival of motor neuron 2, centromeric (SMN2) (for example, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications and deletions, and mobile element insertions
• 0238U — Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
• 0620T — Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed
• 33995 — Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only
• 58999 — Unlisted Proc, Female Genital System (Nonobstetrical)
• 81191 — Neurotrophic receptor tyrosine kinase 1 (NTRK1) (for example, solid tumors) translocation analysis
• 81192 — Neurotrophic receptor tyrosine kinase 2 (NTRK2) (for example, solid tumors) translocation analysis
• 81193 — Neurotrophic receptor tyrosine kinase 3 (NTRK3) (for example, solid tumors) translocation analysis
• 81194 — Neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3 (NTRK) (for example, solid tumors) translocation analysis
• 81279 — Janus kinase 2 (JAK2) (for example, myeloproliferative disorder) targeted sequence analysis (for example, exons 12 and 13)
• 81338 — MPL proto-oncogene, thrombopoietin receptor (MPL) (for example, myeloproliferative disorder) gene analysis; common variants (for example, W515A, W515K, W515L, W515R)
• 81339 — MPL proto-oncogene, thrombopoietin receptor (MPL) (for example, myeloproliferative disorder) gene analysis; sequence analysis, exon 10
• 81351 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; full gene sequence
• 81352 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (for example, 4 oncology)
• 81353 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; known familial variant
• 81546 — Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (for example, benign or suspicious)
• C1778 — Lead, neurostimulator (implantable)
• C1883 — Adaptor/extension, pacing lead or neurostimulator lead (implantable)
• G0068 — Professional services for the administration of antiinfective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0069 — Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0070 — Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0088 — Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0089 — Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes
• G0090 — Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes

 

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

• Web: Once logged in to Availity* at availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate.
• Fax: 800-964-3627
• Phone: 855-558-1443

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at mediproviders.anthem.com/wi > Login. Contracted and noncontracted providers who are unable to access the provider website may call our Provider Services at 855-558-1443 for assistance with PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

 

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