4/29/2019
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Posted by Fidelis Care
The following sections of the Fidelis Care authorization grids have been updated
effective June 1, 2019.
The following services apply to all lines of business and require prior authorization:
IV. or V. Outpatient and DME Services:
E. Imaging Studies*:
Five or more ultrasounds for a normal pregnancy: diagnosis code Z32.01 (added)
(*refer to the online authorization grid for the full description on E. Imaging Studies)
VIII. or IX. Pharmacy:
• These injectable codes require prior authorization: J2787, Q4081 (excludes Medicare) (added)
• These injectable codes do not require authorization:
C9035, C9037, J2358, J2426, J2794 (removed)
Visit: Authorization Grids