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Fidelis Care Authorization Grids Effective April 1, 2024
2/28/2024 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated effective April 1, 2024.

 

The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:

H.  Therapeutic Services:                                                           

1.      Pain Management Codes (i.e. injections, TENS, therapeutic services): 20526, 20550, 20551, 20552, 20553, 21073, 27096, 62263-62264, 62273, 62280, 62281, 62282, 62290, 62320, 62321, 62322, 62323, 62324, 62325, 62326,  62327, 63622, 64400-64530, 64553-64595, 64600-64640, 64582, 64583, 64628, 64629          

                              Note: 63622 does not require authorization for requests from orthopedic specialties.                                                        

a.       Interventional Pain Management: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, C1778, C1787, C1883, C1897                                              

 

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

A4238  Supply allowance for adjunctive, non-implanted CGM

A4239  Supply allowance for non-adjunctive, non-implanted CGM

E2201  Manual wheelchair accessory, nonstandard seat frame, width 20-24 in.

E2202  Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches

 

The following code has been added on the Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:

C9293 glucarpidase (Voraxaze)

 

Visit:  Authorization Grids

 

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