The following section of the Fidelis Care authorization grids have been updated effective May 1, 2025.
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Ambetter Metal-Level Products Authorization Grids and require prior authorization:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures:
- 11730 requires an authorization when billed with REV codes 0360, 0361 and 0490
- Only the following codes require authorization for any place of service: A2030, A2031, A2032, A2033, A2034, A2035, 11200, 11201, 11719, 15769 - 15829, 17340-17999, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367
R. Other: C1600, C1601, C1602, C1603, C1604, C1737, C7556, C7557, C7560, C9807, 23140, 54360 , 60660, 60661
The following codes have been updated on the Medicare Authorization Grid and require prior authorization:
V. Counseling Services Authorization requirements are indicated.
A. Medical Nutrition Therapy (MNT)
- Up to 12 visits per year are covered without an authorization using codes 97802 or 97803 or G0270 and G0271. A 15 or a 30 minute session counts as one visit
The following DME codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:
| A6515 | Gradient compression wrap with adjustable straps, full leg, each, custom |
| A6516 | Gradient compression wrap with adjustable straps, foot, each, custom |
| A6517 | Gradient compression wrap with adjustable straps, below knee, each, custom |
| A6518 | Gradient compression wrap with adjustable straps, arm, each, custom |
| A6519 | Gradient compression garment, not otherwise specified, for nighttime use, each |
| A6611 | Gradient compression wrap with adjustable straps, above knee, each, custom |
| E0201 | Penile contracture device, manual, greater than 3 lbs traction force |
| E1022 | Wheelchair transportation securement system, any type includes all components and accessories |
| E1023 | Wheelchair transit securement system, includes all components and accessories |
| E1032 | Wheelchair accessory, manual swingaway, retractable or removable mounting hardware used with joystick or other drive control interface |
| E1033 | Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type |
| E1034 | Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type |
| E1832 | Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories |
| L0720 | Cervical-thoracic-lumbar-sacral-orthoses (ctlso), anterior-posterior-lateral control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1933 | Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, off-the-shelf |
| L1952 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, off-the-shelf |
| L5827 | Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping |
| L6028 | Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, not including inserts described by l6692 |
| L6029 | Upper extremity addition, test socket/interface, partial hand including fingers |
| L6030 | Upper extremity addition, external frame, partial hand including fingers |
| L6031 | Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power |
| L6032 | Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal) |
| L6033 | Addition to upper extremity prosthesis, partial hand including fingers, acrylic material |
| L6037 | Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers |
| L6700 | Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement |
| L7406 | Addition to upper extremity, user adjustable, mechanical, residual limb volume management system |
The following section of the Fidelis Care authorization grids have been updated effective April 1, 2025.
The following codes have been updated on the Medicaid, CHP, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:
J2428 paliperidone palmitate extended release inj (Erzofri)
The following codes have been updated on the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization:
C9301 obecabtagene autoleucel (Auctazyl)
C9302 zanidatamab-hrii inj (Ziihera)
C9303 zolbetuximab-clzb inj (Vyloy)
C9304 marstacimab-hncq inj (Hympavzi)
J0281 aminocaproic acid inj
J1072 testosterone cypionate inj, (Azmiro)
J1299 eculizumab inj (Soliris)
J2351 ocrelizumab and hyaluronidase-ocsq inj (Ocrevus Zunovo)
J2804 rifampin inj
J9024 atezolizumab and hyaluronidase-tqjs inj (Tecentriq Hybreza)
J9038 axatilimab-csfr inj (Niktimvo)
J9054 bortezomib inj (Boruzu)
J9161 denileukin diftitox-cxdl inj (Lymphir)
Q2057 Afamitresgene autoleucel (Tecelra)
Q5147 aflibercept-ayyh inj (Pavblu)
Q5148 filgrastim-txid inj (Nypozi)
Q5149 aflibercept-abzv inj (Enzeevu)
Q5150 aflibercept-mrbb inj (Ahzantive)
Q5151 eculizumab-aagh inj (Epysqli)
Q5152 eculizumab-aeeb inj (Bkemv)
Q9999 ustekinumab-aauz inj (Otulfi)
The following codes require Evolent Oncology (NCH) review for Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans:
C9302 zanidatamab-hrii inj (Ziihera)
C9303 zolbetuximab-clzb inj (Vyloy)
J9024 atezolizumab and hyaluronidase-tqjs inj (Tecentriq Hybreza)
J9054 bortezomib inj (Boruzu)
J9161 denileukin diftitox-cxdl inj (Lymphir)
Q5148 filgrastim-txid inj (Nypozi)
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