Fidelis Care Authorization Grids Effective November 1, 2025
9/29/2025
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective November 1, 2025.
The following codes have been updated on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures:
- Only the following codes require authorization for any place of service: A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, 11200, 11201, 11719, 15769-15829, 17340-17999, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397
The following sections have been added on the Medicaid Authorization Grid and requires prior authorization:
R. Family Psychotherapy
Covered; Authorization Required for CPT Codes 90847
Effective 11/1/25, Fidelis Care will have utilization management requirements for Family Psychoeducation for any requests after the initial 24 units.
S. Group Psychotherapy
Covered; Authorization Required for CPT Codes 90853
Effective 11/1/25, Fidelis Care will have utilization management requirements for Group Psychoeducation for any requests after the initial 24 units.
The following code has been added to the Medicaid DME Authorization grid and requires prior authorization for Medicaid, Medicare, Essential Plan, and Metal-Level lines of business:
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E0150
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Combination wheeled walker with seat and transport chair, folding, adjustable or fixed height
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E0658
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Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full arms and chest
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E0659
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Segmental pneumatic appliance for use with pneumatic compressor, integrated, head, neck and chest
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L1007
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Scoliosis orthosis (SO), sagittal-coronal control provided by a rigid lateral frame, extends from axilla, to trochanter, includes all accessory pads, straps, and interface, custom fabricated
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L5657
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Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials
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L6034
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Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692
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L6035
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Single prosthetic digit, mechanical, can include metacarpophalangeal (MCP), proximal interphalangeal (PIP), and/or distal interphalangeal (DIP) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement
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L6036
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Prosthetic thumb, mechanical, can include metacarpophalangeal (MCP), interphalangeal (IP) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement
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L6038
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Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material
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L6039
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Passive prosthetic digit or thumb prosthesis not including hand restoration partial hand, full or partial, custom made, any material, initial or replacement, per single passive prosthetic digit or thumb
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Visit: Authorization Grids