Added codes
Effective April 1, 2022
Amniotic
Membrane and Amniotic Fluid, 7.01.583
Now requires review for investigational.
Q4224, Q4225, Q4256, Q4257, Q4258
Antibody-Drug
Conjugates, 5.01.582
Now requires review for medical necessity and prior authorization.
J9273, J9359
Bioengineered
Skin and Soft Tissue Substitutes, 7.01.113
Now requires review for investigational.
A2011, A2012, A2013
Drugs
for Rare Diseases, 5.01.576
Now requires review for medical necessity.
C9090
Drugs
for Rare Diseases, 5.01.576
Now requires review for medical necessity and prior authorization.
J0219
Medical
Necessity Criteria for Pharmacy Edits, 5.01.605
Now requires review for medical necessity and prior authorization.
J0879
mTOR
Kinase Inhibitors, 5.01.533
Now requires review for medical necessity.
C9091
Non-covered
Services and Procedures, 10.01.517
Not covered.
H2038, T2050, T2051
Non-covered
Experimental/Investigational Services, 10.01.533
Now requires review for investigational.
0489T, 0490T, K1028, K1029
Pharmacotherapy
of Miscellaneous Autoimmune Diseases, 5.01.564
Now requires review for medical necessity and prior authorization.
J0491
Prescription
Digital Therapeutics, 13.01.500
Now requires review for investigational.
A9291
Serum
Biomarker Panel Testing for Systemic Lupus Erythematosus and Other Connective
Tissue Diseases, 2.04.123
Now requires review for investigational.
0312U
Vascular
Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders,
5.01.620
Now requires review for medical necessity.
C9093
Vascular
Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders,
5.01.620
Now requires review for medical necessity and prior authorization.
Q5124
AIM
Specialty Health® Genetic Testing
Now reviewed by AIM Specialty Health® for medical necessity and prior authorization.
0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U
Revised codes
Effective April 1, 2022
Electrostimulation and
Electromagnetic Therapy for Treating Wounds, 2.01.57
No longer requires review for medical necessity. Now requires review for investigational and prior authorization
E0761
Removed codes
Effective April 1, 2022
Antibody-Drug Conjugates,
5.01.582
No longer requires review. Code terminated.
C9084
Drugs for Rare Diseases, 5.01.576
No longer requires review. Code terminated.
C9085
Pharmacotherapy
of Miscellaneous Autoimmune Diseases, 5.01.564
No longer requires review. Code terminated.
C9086
Pharmacotherapy
of Miscellaneous Autoimmune Diseases, 5.01.564
No longer requires review for medical necessity and prior authorization.
Q5109