Health Equity

The following sections of the Fidelis Care authorization grids have been updated effective April 1, 2026.

The following codes have been added to the Medicaid Authorization Grid and requires prior authorization:

III.       Outpatient surgery: The following services require prior authorization:               

                     A.  Bariatric surgery: 43644, 43645                                 

                     D.  Skin surgery and other dermatological procedures:

• Only the following codes continue to require authorization for any place of service: 15271, 15274, 15275, 15276                                

                     M.  Spinal Surgery: 22830, 63200                       

                     R.  Other: 11043, 15736, 15738, 25447, 27702, 28285, 28296, 58545, 62350, 62362, 92920                                   

V.        Outpatient and DME Services: The following services require prior authorization:             

                    A.    Diagnostic testing                               

7.  Other services: 95700, 95712, 95713, 95714, 95715, 95716, 95718, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 97007, 97008, 97009                      

The following codes have been added to the Essential Plan, and Qualified Health Plan Authorization Grids and require prior authorization:

III.       Outpatient surgery: The following services require prior authorization:

                  R. Other: 15734, 15736, 15738, 25111, 29848       

V.        Outpatient and DME Services: The following services require prior authorization:

                 A.    Diagnostic testing       

            5.  Proprietary Laboratory Analysis  0037U       

            6.  Other services: 97007, 97008, 97009

The following codes have been added to the Medicare Authorization Grid and require prior authorization:

II.         Outpatient surgery: The following services require prior authorization:                     

                  H.  Eyelid & ocular surgery: 67917, 67924, 67950                   

                  Q.  Other: 15734, 15736, 15738, 97597             

IV.       Outpatient and DME Services: These services require prior authorization:                

                    A.  Diagnostic Testing:                   

                 4.  Gastroenterology Procedures          

                      · Authorization is required for 43290, 43775, 43889, and 43999 when performed in any place of service          

                               8.  Other services: 97007, 97008, 97009            

The following codes have been updated on the Medicaid and CHP Authorization Grid and require prior authorization:

J0485    belatacept, inj

J0604    cinacalcet, oral

J0878    daptomycin, inj

J1437    ferric derisomaltose, inj

Q4081  epoetin alfa, inj (esrd on dialysis)

The following codes have been updated on the Medicaid, CHP, Essential Plan, and Qualified Health Plan Plans Authorization Grids and require prior authorization:

J3240     thyrotropin alpha, inj

Q0138   ferumoxytol, inj (non-esrd)

Q0139   ferumoxytol, inj (esrd on dialysis)

Q5105   epoetin alfa-epbx, inj (esrd on dialysis)

B4100    Food thickener (For members ages 21 and over)

The following codes have been updated on the Medicaid, CHP, Essential Plan, Qualified Health Plan, and Medicare Authorization Grids and require prior authorization:

J1572     immune glob (flebogamma/flebogamma dif)

B4152    Enteral formula, nutritionally complete, calorically dense

The following codes have been added to the Medicaid DME Authorization Grid and require prior authorization:

Visit:  Authorization Grids