Fidelis Care Authorization Grids Effective January 1, 2022 (Updated)
12/13/2021
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2022.
The Medicaid, Medicare, Essential Plan, & Metal Level Plan grids have been updated as follows:
Elective Surgical Procedure: the List of Inpatient Only Procedures has been updated for 2022.
Outpatient surgery: The following services require prior authorization:
- Eyelid and Ocular Procedures: new codes 66989, 66991, & 68841 added.
- Speech Processor Implant Procedures (new category): 69716, 69719, 69726, & 69727.
- “Esophageal sphincter augmentation” has been updated to “Esophageal procedures”: added 43497.
Outpatient and DME Services: The following services require prior authorization:
- Diagnostic testing - Wireless Motility capsule: added 91113.
- Imaging Studies - TBS Scans: 77089, 77090, 77091, & 77092 added.
- Therapeutic Services - Pain Management Codes: 64582, 64583, 64628, & 64629 added.
- Therapeutic Services – “Other” Category: 61736, 61737 added.
The following changes apply to the Medicaid line of business only:
“DME and pharmaceutical treatment for Erectile Dysfunction” has been updated to be “DME, Services, and Pharmaceutical treatment for erectile dysfunction”; codes 54408,54410,54411,54416,54417,& 55870 added.
Pharmacy:
- These codes require authorization under Medicaid, Medicare, Essential Plan, & Metal Level Plans.
C9085 avalglucosidase alfa-ngpt inj
C9086 anifrolumab-fnia
J0172 adacanumab-avwa (Aduhelm)
J1952 leuprolide inj (Camcevi)
J2506 pegfilgrastim (Neulasta) *formerly J2505
J9021 asparaginase rec (Rylaze) inj
J9061 amivantamab-vmjw inj
J9272 dostarlimab-gxly inj
Q2055 idecabtagene vicleucel (Abecma)
- The following codes have been removed from the authorization grids specified:
J2505 – changed to J2506, removed for All Lines of Business
S0013 esketamine nasal spray – removed from Medicaid
C9081 Idecabtagene vicleucel (Abecma) – removed from Medicare
C9082 dostarlimab-gxly (Jemperli) – removed from Medicare
C9083 amivantamab-vmjw (Rybrevant) – removed from Medicare
Visit: Authorization Grids
COVID-19 UPDATE: Please refer to this link: Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.