Fidelis Care Authorization Grids Effective October 1, 2022
9/1/2022
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective October 1, 2022.
The Essential Plan, Medicaid, Medicare and Metal-Level Products grids have been updated as follows:
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing:
2. Breast Cancer testing (BRCA) and other Genetic Testing (Note: Authorization is not required for CPT 81220, 81329, 81336 and 81420. CPT 81220 has a lifetime limit of 1. CPT 81329 and 81336 have a combined limit of 1 per lifetime.)
The following codes have been updated on the Essential Plan, Medicaid, Medicare and Metal-Level Products grids and require prior authorization:
C9142 bevacizumab-maly (Alymsys)
J1302 sutimlimab-jome (Enjaymo)
J1932 lanreotide
J2777 faricimab-svoa (Vabysmo)
J9274 tebentafusp-tebn (Kimmtrak)
J9298 nivolumab and relatlim a b-rmbw (Opduakag)
Q2056 ciltacabtagene autoleuce (Carvykti)
Q5125 filgrastim-ayow, biosimilar, (Releuko)
The following codes have been added to the Medicaid DME authorization grid and require prior authorization:
A4232
|
L1852
|
L3550
|
L5718
|
L7400
|
A7046
|
L2200
|
L3560
|
L5782
|
L7401
|
B4105
|
L2240
|
L3590
|
L5848
|
L7402
|
E0484
|
L3001
|
L3595
|
L5859
|
L7403
|
E2301
|
L3031
|
L3761
|
L5961
|
L7404
|
K1013
|
L3500
|
L4392
|
L6647
|
L7405
|
K1022
|
L3510
|
L4394
|
L6648
|
L7700
|
L0859
|
L3520
|
L5616
|
L6715
|
|
L1851
|
L3530
|
L5617
|
L6880
|
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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.