Medicare Advantage training, Medicare balance, and prior authorization updates in January 2023

Featured story: Make the most of virtual health visits with these 5 tips

Virtual healthcare visits increased gradually but slowly before the Covid-19 pandemic. But then stay-at-home orders and lockdowns turned telemedicine from a potential option into a necessity. 

When Medicare expanded the use of federal funds for telehealth visits—and the Department of Health and Human Services (HHS) relaxed privacy restrictions so health providers could use platforms like FaceTime, Microsoft Teams, and Zoom—the boom was official, and there's no going back. In the past couple of years, the widespread use of telehealth has highlighted its effectiveness and benefits. 

iStock-1199215126

Continue reading 

 

In this issue

  • Watch our Medicare Advantage training video
  • Crisis Intervention – ED Boarding
  • Medicare balance
  • Medicare Advantage diagnosis codes
  • Prior Authorization Lift for Inpatient Post-Acute Care (PAC) 
  • Hospital inpatient utilization report
  • Mass Standard Oncology Chemo Form
  • Early Intensive Behavioral Intervention (EIBI) providers
  • Medical policy updates
  • Formulary updates
  • Reminders: Rebrand and Medicare Advantage
  • HCPCS codes
  • Code updates
  • Drug code updates

 

Watch our Medicare Advantage training video

In this training, we'll cover:

  • Medicare Advantage plan details
  • The Medicare Advantage network
  • Helpful resources
  • What to expect next

 

 

 


Crisis Intervention – ED Boarding

Mass General Brigham Health Plan reimburses medical facilities for the provision of medically necessary, crisis intervention services to treat and stabilize to Mass General Brigham Health Plan members awaiting an inpatient acute psychiatric placement in a facility emergency department (ED) or observation setting. For more information, click here


Medicare Balance

Medicare Balance is a state-regulated product that complements Medicare coverage or “wraps” around Medicare coverage by paying for the member’s Medicare deductibles and coinsurance minus any applicable plan copays. Also known as an “Indemnity Plan, ” members may access medical care from any provider who accepts Medicare payment.

Medicare Balance is a state-regulated product that complements Medicare coverage or “wraps” around Medicare coverage by paying for the member’s Medicare deductibles and coinsurance minus any applicable plan copays. Also known as an “Indemnity Plan, ” members may access medical care from any provider who accepts Medicare payment.

 

Key features:

  • No provider network

  • No primary care physician required

  • No referrals or prior authorizations required

  • Individual subscriber product (no family policies)

How Providers can submit claims for Medicare Balance:

  • Claims for Medicare Balance should be submitted to Medicare first

  • Medicare will process the primary claim and send payment to the provider

  • The Benefits Coordination and Recovery Center (BCRC) will then electronically “cross-over” the secondary claim to Mass General Brigham Health Plan

  • Mass General Brigham Health Plan will process the secondary claim and remit payment to the provider

  • Providers bill once and are paid twice. First by Medicare and then by Mass General Brigham Health Plan

  • Providers should not submit claims directly to Mass General Brigham Health Plan

For more info visit our claims page.


Medicare Advantage diagnosis codes

Beginning 1/1/2023, as a requirement for Medicare Advantage,  providers will be required to submit a diagnosis code on any authorization requests submitted via the Provider Portal for Medicare Advantage members.

 


Prior Authorization Lift for Inpatient Post-Acute Care (PAC) 

For dates of service 12/6/22 through 3/6/23 prior authorization review is suspended for initial review for members transferring from inpatient admissions at Acute Care hospitals, to Inpatient Post-Acute Care Facilities: skilled nursing facilities or acute rehab facilities. This does not include long-term or custodial admissions or homecare. Notifications should be submitted by the provider within 24 hours of admission and updates provided a minimum of every 5 days to enable Mass General Brigham Health Plan to support discharge planning. Concurrent review and retrospective review will proceed to determine the appropriateness of the level of care.

This applies to all lines of business as follows:
•    12/06/22-3/06/23: Commercial, Medicaid
•    1/1/23-3/06/23: Medicare Advantage (MA)

 


Hospital inpatient utilization report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register online at provider.massgeneralbrighamhealthplan.org.


Mass Standard Oncology Chemo Form

As of 12/1/22, AllWays Health Partners will be accepting the Mass Standard Oncology Chemo Form when requesting Oncology and Supportive care services. For more information, please visit DOI Bulletin 2022-07 (mass.gov). The form and other helpful Medical Specialty Pharmacy information can be found on our website. 

Here is a link to the form: MASSACHUSETTS STANDARD FORM FOR CHEMOTHERAPY

Please note, as of February 1, 2023 this form will be required for all Oncology and Supportive care services. In addition, this form will be available electronically as of February 1, 2023.


Early Intensive Behavioral Intervention (EIBI) providers

Reminder: an important update for EIBI providers who see AllWays Health Partners members under 3 with an autism diagnosis who are also involved with Early Intervention.

What you need to know

  • For dates of service starting 10/01/2022, EIBI providers must adopt the codes published by the Executive Office of Health and Human Services (EOHHS) in 101 CMR 358.00.
  • AllWays Health Partners is updating prior authorization and claims systems to ensure EIBI providers can submit a prior authorization and receive accurate and timely claims payment based on the codes and rates published in 101 CMR 358.00.

EOHHS code mapping:

EOHHS codes for EIBI providers 1122

You can find the medical policy here and the payment guidelines here


Rebrand reminder

AllWays Health Partners is now Mass General Brigham Health Plan as of January 1, 2023, to reflect and advance the system’s unique provider-payer integration that is improving health outcomes, reducing costs, and transforming the healthcare experience.

Please visit our Rebrand Provider FAQ for the latest information about our new name.


Medicare Advantage reminder

Under our new name, we are offering our first-ever Medicare Advantage products. This will give us the opportunity to support a growing population with a broad range of healthcare needs.

Please visit our Medicare Advantage Provider Page, as this will be updated on an ongoing basis with the latest information available.


Medical policy updates

Three medical policies were reviewed and passed by the Mass General Brigham Health Plan’s Medical Policy Committee. These policies are now posted to MassGeneralBrighamHealthPlan.org. The table below is a summary. For more information or to download our medical policies, go to massgeneralbrighamhealthplan.org/providers/medical-policies and select the policy under the medical policy listings.

 

 

Medical Policies

Policy Title

Summary

Products Affected

Effective Date

HIV-Associated Lipodystrophy Syndrome

January 2023 Annual review. References updated.

Commercial and Qualified Health Plans

1/1/2023

Breast Surgeries

January 2023: Annual Review. The following changes were made:

•   Under Coverage Guidelines; added clarifying statement about following MassHealth medical necessity criteria.

•   Under Breast Reconstruction Surgery; added coverage language to include nipple surgery/repair, and mastopexy.

•   Under Gender Affirming Procedures; added mastopexy. Added term “incongruence” to align with WPATH.

•   Under Breast Reconstruction Related to Other Medical Conditions; added amazia as additional medical condition.

•   Edited Nipple Repair subheading to include surgery. Added #2 under subheading.

•   Clarified exclusion #3 to include Gender Affirming Procedure.

•   References updated.

Commercial and Qualified Health Plans

1/1/2023

Insulin Pumps

January 2023: Annual Review Under Overview section, added insulin pumps. Under Coverage Guidelines section, MassHealth statement section added.

Commercial and Qualified Health Plans

1/1/2023

In addition, as of January 2023, AllWays Health Partners is now Mass General Brigham Health Plan. As such, all customized InterQual criteria has been rebranded and you will see the new company name in the criteria.

To access this criteria, providers should log in to Mass General Brigham Health Plan’s provider website at MassGeneralBrighamHealthPlan.org and click the InterQual® Criteria Lookup link under the Resources Menu.


Formulary updates

Effective 03/01/2023

DEFINITIONS:


Formulary: These drugs are included in AllWays Health Partners’ covered drug list. 

Non-Formulary: These drugs are not included in AllWays Health Partners’ formulary. AllWays Health Partners would only cover formulary alternatives. Providers can request Non-Formulary drugs as an exception, and AllWays Health Partners would require trial of all appropriate formulary alternatives prior to approving coverage of a Non-Formulary drug. If a Non-Formulary drug is approved, the member’s cost sharing would be the highest tier.

Preferred: These drugs are on AllWays Health Partners’ formulary and offer a lower cost to members. 

Non-Preferred: These drugs are on AllWays Health Partners’ formulary but offer a higher cost to members.

Excluded: AllWays Health Partners does not cover these drugs. Members will receive a denial for all Excluded drug requests.

Updates for Commercial Members

The following changes are being made to the listed medications: 

Nucala

The following has been added to the pharmacy benefit with prior authorization:

·       Nucala prefilled syringe and injectable solution

Both will remain on medical benefit as well.

 

Nucala auto-injector will remain on the pharmacy benefit only.

 

Fasenra

The following has been added to the pharmacy benefit with prior authorization:

·       Fasenra prefilled syringe

                       This will remain on medical benefit as well.

 

Fasenra Auto injectors will remain on the pharmacy benefit only

Viibryd Starter Kit

The following will no longer be considered formulary and will be non-formulary:

·       Viibryd Starter Kit

 

Generic Vilazodone is formulary and is available in the following strengths:

·       10mg, 20mg, and 40mg.

Updates for My Care Family Members

The following changes are being made to the listed medications:

MassHealth Unified Pharmacy Product List (UPPL) Updates

Breast Cancer Therapies

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Tykerb, Afinitor, Afinitor Disperz were added

·       Verbiage regarding combination therapy was updated throughout

·       Specific diagnoses are listed within criteria for each drug

·       Appendix “Requests which do not clearly document postmenopausal status” was removed

Cerebral Stimulants & ADHD

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses are listed within criteria for each drug

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators

Criteria was updated to include FDA-expanded age indication for Orkambi from ≤2 to ≤1 years of age.

 

New strengths and quantity limits (QL) were added for the following:

·       Orkambi 100-125mg tablet with QL 112 tablets per 28 days

·       Orkambi 75-94mg granule with QL 56 packets per 28 days

·       Orkambi 100-125mg granule with QL 56 packets per 28 days

·       Trikafta 50-25-37.5mg tablet with QL 84 tablets per 28 days

Kinase Inhibitors

Criteria for everolimus was updated to allow appropriate specialist for the requested indication, in place of just an oncology specialist. This applies to the following indications:

·       renal angiomyolipoma with tuberous sclerosis complex (TSC)

·       advanced pancreatic neuroendocrine tumors (PNET)

·       advanced neuroendocrine tumors (NET) of gastrointestinal or lung origin

·       subependymal giant cell astrocytoma (SEGA) with TSC

 

Step criteria of Inlyta and Keytruda combination for advanced RCC (clear cell histology) was removed from Cabometyx and Lenvima criteria.

 

Retevmo criteria was updated to include the expanded indication of adults with locally advanced or metastatic solid tumors with a rearranged during transfection (RET) gene fusion.

 

Ayvakit criteria was updated to require BOTH of the following:

·       Aggressive SM without the D816V c-Kit mutation or with c-Kit mutation status unknown + t/f with imatinib, and

·       D816V c-Kit mutation positive.

Off-label indications are now included within criteria:

·       Koselugo for Plexiform Neurofibromatosis Type 1 ≥ 18 years of age

·       Nexavar for FLT3-ITD mutated AML

The preferred drug status was removed from Inlyta and Sutent.

 

Lung Cancer Agents

Portrazza, Rybrevant, and Zepzelca will now require a prior authorization in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List).

The following quantity limits were updated:

Alunbrig 30 mg – 60 tablets per 30 days

Lorbrena 25 mg – 30 tablets per 30 days

 

Adlarity

(donepezil transdermal)

This medication will now require a prior authorization in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List) with a quantity limit of 4 patches per 28 days.

 

Inhaled Respiratory Agents

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Gastroenterology was added as a specialty requirement for off-label utilization of budesonide for eosinophilic esophagitis

·       Off-label indication for Pulmicort suspension ≥ 13 years of age was included in criteria

Xeljanz

(tofacitinib citrate)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Removed the option for a low-cost alternative trial with traditional DMARDs for Xeljanz requests in PJIA and RA. Now will require only require treatment failure with an anti-TNF

·       Quantity limit for Xeljanz oral solution will now be 20 mL/day

·       Off-label indications: alopecia areata, HS, plaque psoriasis is included within criteria

·       Initial approval durations were clarified

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Strengths of 11 mg and 1 mg/mL solution were added to criteria

 

Cimzia

(certolizumab pegol)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       It was noted in all indications to bypass required biologic trials if a provider documents that Cimzia is preferred because the member is pregnant, breastfeeding or planning to become pregnant

Otezla

(apremilast)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Low-cost alternative trial requirement in PsA was removed

·       Off-label indications are now included within criteria

Kineret, Skyrizi, Stelara, Humira, Enbrel, Cosentyx, Siliq, Kevzara, Ilumya, Tremfya

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Off-label indications are now included within criteria

Rinvoq

(upadacitinib)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Off-label indications are now included within criteria

·       Requirement of contraindication to BOTH Xeljanz and Xeljanz XR for psoriatic arthritis criteria

·       Removed the option for a low-cost alternative trial with traditional DMARDs for requests in RA and to specifically require an anti-TNF agent trial

Infliximab Agents

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Off-label indications are now included within criteria

·       Added language regarding stability of requested medication for new members: Requests for Avsola and unbranded infliximab that document stability for any FDA-approved indication at an FDA-approved dose can be approved

·       Requests for Inflectra or Renflexis that document stability can be approved without documentation of failed trials with the preferred infliximab agents for ankylosing spondylitis or Crohn’s disease

Olumiant

(baricitinib)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Removed requirement of a trial with an anti-TNF agent for RA

 

Taltz

(ixekizumab)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List) such as having specific diagnoses throughout the criteria.

Simponi

Simponi Aria

Orencia

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

 

Actemra

(tocilizumab)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Language regarding stability of requested medication for new members with a documented history of hospitalization was added

 

Zeposia

(ozanimod)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” throughout criteria

·       Removed requirement trial with Entyvio for Ulcerative Colitis

Entyvio

(vedolizumab)

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List). Updates included the following:

·       Specific diagnoses have replaced “appropriate diagnosis” through criteria

·       Removed trial requirements from UC and CD criteria

·       Avsola was added as a trial requirement for fistulizing CD

Anticonvulsants

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List) such as adding off-label indications within criteria.

Chronic Myelogenous Leukemia Agents (CML)

The preferred drug designation has been removed from Bosulif in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List).

Lymphoma and Leukemia agents

Criteria updated to include two off label indications (Venclexta for MM, Imbruvica for CNS Lymphoma).

Melanoma agents

Criteria was updated in order to be in compliance with the MassHealth UPPL (Unified Pharmacy Product List) such as adding off-label indications within criteria.

COVID-19 OTC Testing Kits

Criteria was updated to include CVS COVID-19 and Genabio testing kits with a quantity limit of 8 tests per 28 days.

 


New January 2023 HCPCS codes

Not covered Experimental and Investigational:

C1747

Endoscope, single-use (i.e. disposable), urinary tract, imaging/illumination device (insertable)

C1826

Generator, neurostimulator (implantable), includes closed feedback loop leads and all implantable components, with rechargeable battery and charging system

C1827

Generator, neurostimulator (implantable), non-rechargeable, with implantable stimulation lead and external paired stimulation controller

Q4262

Dual layer impax membrane, per square centimeter

Q4263

Surgraft tl, per square centimeter

Q4264

Cocoon membrane, per square centimeter

 

Reportable Only; Not Reimbursable:

M0001

Advancing cancer care mips value pathways

M0002

Optimal care for kidney health mips value pathways

M0003

Optimal care for patients with episodic neurological conditions mips value pathways

M0004

Supportive care for neurodegenerative conditions mips value pathways

M0005

Promoting wellness mips value pathways

M1150

Left ventricular ejection fraction (lvef) less than or equal to 40% or documentation of moderately or severely depressed left ventricular systolic function

M1151

Patients with a history of heart transplant or with a left ventricular assist device (lvad)

M1152

Patients with a history of heart transplant or with a left ventricular assist device (lvad)

M1153

Patient with diagnosis of osteoporosis on date of encounter

M1154

Hospice services provided to patient any time during the measurement period

M1155

Patient had anaphylaxis due to the pneumococcal vaccine any time during or before the measurement period

M1156

Patient received active chemotherapy any time during the measurement period

M1157

Patient received bone marrow transplant any time during the measurement period

M1158

Patient had history of immunocompromising conditions prior to or during the measurement period

M1159

Hospice services provided to patient any time during the measurement period

M1160

Patient had anaphylaxis due to the meningococcal vaccine any time on or before the patient's 13th birthday

M1161

Patient had anaphylaxis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient's 13th birthday

M1162

Patient had encephalitis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient's 13th birthday

M1163

Patient had anaphylaxis due to the hpv vaccine any time on or before the patient's 13th birthday

M1164

Patients with dementia any time during the patient's history through the end of the measurement period

M1165

Patients who use hospice services any time during the measurement period

M1166

Pathology report for tissue specimens produced from wide local excisions or re-excisions

M1167

In hospice or using hospice services during the measurement period

M1168

Patient received an influenza vaccine on or between july 1 of the year prior to the measurement period and june 30 of the measurement period

M1169

Documentation of medical reason(s) for not administering influenza vaccine (e.g., prior anaphylaxis due to the influenza vaccine)

M1170

Patient did not receive an influenza vaccine on or between july 1 of the year prior to the measurement period and june 30 of the measurement period

M1171

Patient received at least one td vaccine or one tdap vaccine between nine years prior to the encounter and the end of the measurement period

M1172

Documentation of medical reason(s) for not administering td or tdap vaccine (e.g., prior anaphylaxis due to the td or tdap vaccine or history of encephalopathy within seven days after a previous dose of a td-containing vaccine)

M1173

Patient did not receive at least one td vaccine or one tdap vaccine between nine years prior to the encounter and the end of the measurement period

M1174

Patient received at least one dose of the herpes zoster live vaccine or two doses of the herpes zoster recombinant vaccine (at least 28 days apart) anytime on or after the patient's 50th birthday before or during the measurement period

M1175

Documentation of medical reason(s) for not administering zoster vaccine (e.g., prior anaphylaxis due to the zoster vaccine)

M1176

Patient did not receive at least one dose of the herpes zoster live vaccine or two doses of the herpes zoster recombinant vaccine (at least 28 days apart) anytime on or after the patient's 50th birthday before or during the measurement period

M1177

Patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 60th birthday and before the end of the measurement period

M1178

Documentation of medical reason(s) for not administering pneumococcal vaccine (e.g., prior anaphylaxis due to the pneumococcal vaccine)

M1179

Patient did not receive any pneumococcal conjugate or polysaccharide vaccine, on or after their 60th birthday and before or during measurement period

M1180

Patients on immune checkpoint inhibitor therapy

M1181

Grade 2 or above diarrhea and/or grade 2 or above colitis

M1182

Patients not eligible due to pre-existing inflammatory bowel disease (ibd) (e.g., ulcerative colitis, crohn's disease)

M1183

Documentation of immune checkpoint inhibitor therapy held and corticosteroids or immunosuppressants prescribed or administered

M1184

Documentation of medical reason(s) for not prescribing or administering corticosteroid or immunosuppressant treatment (e.g., allergy, intolerance, infectious etiology, pancreatic insufficiency, hyperthyroidism, prior bowel surgical interventions, celiac disease, receiving other medication, awaiting diagnostic workup results for alternative etiologies, other medical reasons/contraindication)

M1185

Documentation of immune checkpoint inhibitor therapy not held and/or corticosteroids or immunosuppressants prescribed or administered was not performed, reason not given

M1186

Patients who have an order for or are receiving hospice or palliative care

M1187

Patients with a diagnosis of end stage renal disease (esrd)

M1188

Patients with a diagnosis of chronic kidney disease (ckd) stage 5

M1189

Documentation of a kidney health evaluation defined by an estimated glomerular filtration rate (egfr) and urine albumin-creatinine ratio (uacr) performed

M1190

Documentation of a kidney health evaluation was not performed or defined by an estimated glomerular filtration rate (egfr) and urine albumin-creatinine ratio (uacr)

M1191

Hospice services provided to patient any time during the measurement period

M1192

Patients with an existing diagnosis of squamous cell carcinoma of the esophagus

M1193

Surgical pathology reports that contain impression or conclusion of or recommendation for testing of mmr by immunohistochemistry, msi by dna-based testing status, or both

M1194

Documentation of medical reason(s) surgical pathology reports did not contain impression or conclusion of or recommendation for testing of mmr by immunohistochemistry, msi by dna-based testing status, or both tests were not included (e.g., patient will not be treated with checkpoint inhibitor therapy, no residual carcinoma is present in the sample [tissue exhausted or status post neoadjuvant treatment], insufficient tumor for testing)

M1195

Surgical pathology reports that do not contain impression or conclusion of or recommendation for testing of mmr by immunohistochemistry, msi by dna-based testing status, or both, reason not given

M1196

Initial (index visit) numeric rating scale (nrs), visual rating scale (vrs), or itchyquant assessment score of greater than or equal to 4

M1197

Itch severity assessment score is reduced by 2 or more points from the initial (index) assessment score to the follow-up visit score

M1198

Itch severity assessment score was not reduced by at least 2 points from initial (index) score to the follow-up visit score or assessment was not completed during the follow-up encounter

M1199

Patients receiving rrt

M1200

Ace inhibitor (ace-i) or arb therapy prescribed during the measurement period

M1201

Documentation of medical reason(s) for not prescribing ace inhibitor (ace-i) or arb therapy during the measurement period (e.g., pregnancy, history of angioedema to ace-i, other allergy to ace-i and arb, hyperkalemia or history of hyperkalemia while on ace-i or arb therapy, acute kidney injury due to ace-i or arb therapy), other medical reasons)

M1202

Documentation of patient reason(s) for not prescribing ace inhibitor or arb therapy during the measurement period, (e.g., patient declined, other patient reasons)

M1203

Ace inhibitor or arb therapy not prescribed during the measurement period, reason not given

M1204

Initial (index visit) numeric rating scale (nrs), visual rating scale (vrs), or itchyquant assessment score of greater than or equal to 4

M1205

Itch severity assessment score is reduced by 2 or more points from the initial (index) assessment score to the follow-up visit score

M1206

Itch severity assessment score was not reduced by at least 2 points from initial (index) score to the follow-up visit score or assessment was not completed during the follow-up encounter

M1207

Number of patients screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety

M1208

Number of patients not screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety

M1209

At least two orders for high-risk medications from the same drug class, (table 4), not ordered

M1210

At least two orders for high-risk medications from the same drug class, (table 4), not ordered

 

Prior authorization required:

A4239

Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service

C7504

Percutaneous vertebroplasties (bone biopsies included when performed), first cervicothoracic and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance

C7505

Percutaneous vertebroplasties (bone biopsies included when performed), first lumbosacral and any additional cervicothoracic or lumbosacral vertebral bodies, unilateral or bilateral injection, inclusive of all imaging guidance

C7507

Percutaneous vertebral augmentations, first thoracic and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) using mechanical device (eg, kyphoplasty), unilateral or bilateral cannulations, inclusive of all imaging guidance

C7508

Percutaneous vertebral augmentations, first lumbar and any additional thoracic or lumbar vertebral bodies, including cavity creations (fracture reductions and bone biopsies included when performed) using mechanical device (eg, kyphoplasty), unilateral or bilateral cannulations, inclusive of all imaging guidance

C9144C

Injection, bupivacaine (posimir), 1 mg

E2103

Non-adjunctive, non-implanted continuous glucose monitor or receiver

G0330

Facility services for dental rehabilitation procedure(s) performed on a patient who requires monitored anesthesia (e.g., general, intravenous sedation (monitored anesthesia care) and use of an operating room

J0225

Injection, vutrisiran, 1 mg

J2021

Injection, linezolid (hospira) not therapeutically equivalent to j2020, 200 mg

J2327

Injection, risankizumab-rzaa, intravenous, 1 mg

J9046

Injection, bortezomib, (dr. reddy's), not therapeutically equivalent to j9041, 0.1 mg

J9048

Injection, bortezomib (fresenius kabi), not therapeutically equivalent to j9041, 0.1 mg

J9049

Injection, bortezomib (hospira), not therapeutically equivalent to j9041, 0.1 mg

Q5126

Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg

 

Prior authorization required for ACO plans; no prior authorization required for Commercial plans:

G0320

Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system

G0321

Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system

G0322

The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring)

 

Covered with no prior authorization required:

 

C7500

Debridement, bone including epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed, first 20 sq cm or less with manual preparation and insertion of deep (eg, subfacial) drug-delivery device(s)

C7501

Percutaneous breast biopsies using stereotactic guidance, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, all lesions unilateral and bilateral (for single lesion biopsy, use appropriate code)

C7502

Percutaneous breast biopsies using magnetic resonance guidance, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, all lesions unilateral or bilateral (for single lesion biopsy, use appropriate code)

C7503

Open biopsy or excision of deep cervical node(s) with intraoperative identification (eg, mapping) of sentinel lymph node(s) including injection of non-radioactive dye when performed

C7506

Arthrodesis, interphalangeal joints, with or without internal fixation

C7509

Bronchoscopy, rigid or flexible, diagnostic with cell washing(s) when performed, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed

C7510

Bronchoscopy, rigid or flexible, with bronchial alveolar lavage(s), with computer-assisted image-guided navigation, including fluoroscopic guidance when performed

C7511

Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed

C7512

Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with transendoscopic endobronchial ultrasound (ebus) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s), including fluoroscopic guidance when performed

C7513

Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with transluminal balloon angioplasty of central dialysis segment, performed through dialysis circuit, including all required imaging, radiological supervision and interpretation, image documentation and report

C7514

Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with all angioplasty in the central dialysis segment, and transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all required imaging, radiological supervision and interpretation, image documentation and report

C7515

Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with dialysis circuit permanent endovascular embolization or occlusion of main circuit or any accessory veins, including all required imaging, radiological supervision and interpretation, image documentation and report

C7516

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report

C7517

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, with iliac and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation

C7518

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging, supervision, interpretation and report

C7519

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress

C7520

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) includes intraprocedural injection(s) for bypass graft angiography with iliac and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of the catheter in the distal aorta or ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and radiologic supervision and interpretation

C7521

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography with right heart catheterization with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report

C7522

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with right heart catheterization, with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress

C7523

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report

C7524

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress

C7525

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report

C7526

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress

C7527

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, with endoluminal imaging of initial coronary vessel or graft using intravascular ultrasound (ivus) or optical coherence tomography (oct) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report

C7528

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress

C7529

Catheter placement in coronary artery(ies) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation, with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress

C7530

Dialysis circuit, introduction of needle(s) and/or catheter(s), with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty and all angioplasty in the central dialysis segment, with transcatheter placement of   intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging, radiological supervision and interpretation, documentation and report

C7531

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7532

Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), initial artery, open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7533

Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy

C7534

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7535

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7537

Insertion of new or replacement of permanent pacemaker with atrial transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable debribrillator or pacemake pulse generator (eg, for upgrade to dual chamber system)

C7538

Insertion of new or replacement of permanent pacemaker with ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defribrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system)

C7539

Insertion of new or replacement of permanent pacemaker with atrial and ventricular transvenous electrode(s), with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system)

C7540

Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system, with insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system)

C7541

Diagnostic endoscopic retrograde cholangiopancreatography (ercp), including collection of specimen(s) by brushing or washing, when performed, with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s)

C7542

Endoscopic retrograde cholangiopancreatography (ercp) with biopsy, single or multiple, with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s)

C7543

Endoscopic retrograde cholangiopancreatography (ercp) with sphincterotomy/papillotomy, with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s)

C7544

Endoscopic retrograde cholangiopancreatography (ercp) with removal of calculi/debris from biliary/pancreatic duct(s), with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s)

C7545

Percutaneous exchange of biliary drainage catheter (eg, external, internal-external, or conversion of internal-external to external only), with removal of calculi/debris from biliary duct(s) and/or gallbladder, including destruction of calculi by any method (eg, mechanical, electrohydraulic, lithotripsy) when performed, including diagnostic cholangiography(ies) when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation

C7546

Removal and replacement of externally accessible nephroureteral catheter (eg, external/internal stent) requiring fluoroscopic guidance, with ureteral stricture balloon dilation, including imaging guidance and all associated radiological supervision and interpretation

C7547

Convert nephrostomy catheter to nephroureteral catheter, percutaneous via pre-existing nephrostomy tract, with ureteral stricture balloon dialation, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation

C7548

Exchange nephrostomy catheter, percutaneous, with ureteral stricture balloon dilation, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation

C7549

Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit with ureteral stricture balloon dilation, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation

C7550

Cystourethroscopy, with biopsy(ies) with adjuctive blue light cystoscopy with fluorescent imaging agent

C7551

Excision of major peripheral nerve neuroma, except sciatic, with implantation of nerve end into bone or muscle

C7552

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress, initial vessel

C7553

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography with pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed

C7554

Cystourethroscopy with adjunctive blue light cystoscopy with fluorescent imaging agent

C7555

Thyroidectomy, total or complete with parathyroid autotransplantation

C9143

Cocaine hydrochloride nasal solution (numbrino), 1 mg

G0316

Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services). (do not report g0316 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418, 99415, 99416). (do not report g0316 for any time unit less than 15 minutes)

G0317

Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99306, 99310 for nursing facility evaluation and management services). (do not report g0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99418). (do not report g0317 for any time unit less than 15 minutes)

G0318

Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99345, 99350 for home or residence evaluation and management services). (do not report g0318 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (do not report g0318 for any time unit less than 15 minutes)

G3002

Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate. required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (when using g3002, 30 minutes must be met or exceeded.)

G3003

Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (list separately in addition to code for g3002. when using g3003, 15 minutes must be met or exceeded.)

J0134

Injection, acetaminophen (fresenius kabi) not therapeutically equivalent to j0131, 10 mg

J0136

Injection, acetaminophen (b braun) not therapeutically equivalent to j0131, 10 mg

J0173

Injection, epinephrine (belcher) not therapeutically equivalent to j0171, 0.1 mg

J0283

Injection, amiodarone hydrochloride (nexterone), 30 mg

J0611

Injection, calcium gluconate (wg critical care), per 10 ml

J0689

Injection, cefazolin sodium (baxter), not therapeutically equivalent to j0690, 500 mg

J0701

Injection, cefepime hydrochloride (baxter), not therapeutically equivalent to maxipime, 500 mg

J0703

Injection, cefepime hydrochloride (b braun), not therapeutically equivalent to maxipime, 500 mg

J0877

Injection, daptomycin (hospira), not therapeutically equivalent to j0878, 1 mg

J0891

Injection, argatroban (accord), not therapeutically equivalent to j0883, 1 mg (for non-esrd use)

J0892

Injection, argatroban (accord), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis)

J0893

Injection, decitabine (sun pharma) not therapeutically equivalent to j0894, 1 mg

J0898

Injection, argatroban (auromedics), not therapeutically equivalent to j0883, 1 mg (for non-esrd use)

J0899

Injection, argatroban (auromedics), not therapeutically equivalent to j0884, 1 mg (for esrd on dialysis)

J1456

Injection, fosaprepitant (teva), not therapeutically equivalent to j1453, 1 mg

J1574

Injection, ganciclovir sodium (exela) not therapeutically equivalent to j1570, 500 mg

J1611

Injection, glucagon hydrochloride (fresenius kabi), not therapeutically equivalent to j1610, per 1 mg

J1643

Injection, heparin sodium (pfizer), not therapeutically equivalent to j1644, per 1000 units

J2184

Injection, meropenem (b. braun) not therapeutically equivalent to j2185, 100 mg

J2247

Injection, micafungin sodium (par pharm) not thereapeutically equivalent to j2248, 1 mg

J2251

Injection, midazolam hydrochloride (wg critical care) not therapeutically equivalent to j2250, per 1 mg

J2272

Injection, morphine sulfate (fresenius kabi) not therapeutically equivalent to j2270, up to 10 mg

J2281

Injection, moxifloxacin (fresenius kabi) not therapeutically equivalent to j2280, 100 mg

J2401

Injection, chloroprocaine hydrochloride, per 1 mg

J2402

Injection, chloroprocaine hydrochloride (clorotekal), per 1 mg

J3244

Injection, tigecycline (accord) not therapeutically equivalent to j3243, 1 mg

J3371

Injection, vancomycin hcl (mylan) not therapeutically equivalent to j3370, 500 mg

J3372

Injection, vancomycin hcl (xellia) not therapeutically equivalent to j3370, 500 mg

J9393

Injection, fulvestrant (teva) not therapeutically equivalent to j9395, 25 mg

J9394

Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to j9395, 25 mg

 

Redirect to Optum:

C7900

Service for diagnosis, evaluation, or treatment of a mental health   or substance use disorder,     initial 15-29 minutes, provided remotely by hospital staff who are licensed to provide mental health services under applicable state law(s), when the patient is in their home, and there is no associated professional service

C7901

Service for diagnosis, evaluation, or treatment of a mental health or substance use disorder, initial 30-60 minutes, provided remotely by hospital staff who are licensed to provided mental health services under applicable state law(s), when the patient is in their home, and there is no associated professional service

C7902

Service for diagnosis, evaluation, or treatment of a mental health or substance use disorder, each additional 15 minutes, provided remotely by hospital staff who are licensed to provide mental health services under applicable state law(s), when the patient is in their home, and there is no associated professional service (list separately in addition to code for primary service)

G0323

Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month. (these services include the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, coordination with and/or referral to physicians and practitioners who are authorized by medicare to prescribe medications and furnish e/m services, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team)

 

Redirect to Pharmacy:

 

J2311

Injection, naloxone hydrochloride (zimhi), 1 mg

 

 


Code updates

The following service(s) previously not covered will be covered without prior authorization required for Commercial and ASO Plans:

Code

Description

Effective Date

K1005

Disposable collection and storage bag for breast milk, any size, any type, each

1/1/2023

 

The following service(s) will be covered with prior authorization via CareCentrix for all lines of business:

Code

Description

Effective Date

95800

Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time

1/1/2023

 

The following service(s) will be covered without prior authorization for all lines of business:

Code

Description

Effective Date

91316

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, for intramuscular use

12/8/2022

0164A

Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, booster dose

12/8/2022

91317

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use

12/8/2022

0173A

Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, third dose

12/8/2022

Drug code updates

The following drug(s) are now covered under the medical benefit with prior authorization for MyCare Family Plans:

Code

Description

Brand Name

Effective Date

J1426

Injection, casimersen, 10 mg

 

Amondys 45

12/1/2022

J9039

Injection, blinatumomab, 1 mcg

Blincyto

1/1/2023

 

The following drug(s) are now covered under the medical benefit without prior authorization for Commercial and ASO Plans:

Code

Description

Brand Name

Effective Date

Q9991

Injection, buprenorphine extended-release (Sublocade), less than or equal to 100 mg

Sublocade

12/1/2022

 

Q9992

Injection, buprenorphine extended-release (Sublocade), greater than 100 mg

 

The following drug(s) are now covered under the medical benefit with prior authorization for Commercial and ASO Plans:

Code

Description

Brand Name

Effective Date

No

Specific code

Injection, spesolimab-sbzo IV

HCPCS J3590 can be billed to represent Spevigo 450/7.5 IV until such time CMS assigns a permanent code.

Spevigo 450/7.5

12/1/2022

No

Specific code

Injection, olipudase alfa-rpcp IV

HCPCS J3590 can be billed to represent Xenpozyme IV until such time CMS assigns a permanent code.

Xenpozyme 20mg

12/1/2022