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Fidelis Care Authorization Grids Effective March 1, 2024
1/31/2024 • Posted by Provider Relations

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

 

Evolent (New Century Health) will require review of the following codes for Medicaid, Essential Plans and Metal-Level Products:

J8999 eflornithine (Iwilfin)

J8999 nirogacestat (Ogsiveo)

 

Evolent (New Century Health) will require review of the following codes for Medicare Products:

J8999 eflornithine (Iwilfin) – Part D only

J8999 nirogacestat (Ogsiveo) – Part D only

 

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

 

A4540

Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm

A6582

Gradient compression gauntlet, each

A4542

Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wrist

A6583

Gradient compression wrap with adjustable straps, below knee, 30-50 mmhg, each

A6520

Gradient compression garment, glove, padded, for nighttime use, each

A6584

Gradient compression wrap with adjustable straps, not otherwise specified

A6521

Gradient compression garment, glove, padded, for nighttime use, custom, each

A6585

Gradient pressure wrap with adjustable straps, above knee, each

A6522

Gradient compression garment, arm, padded, for nighttime use, each

A6586

Gradient pressure wrap with adjustable straps, full leg, each

A6523

Gradient compression garment, arm, padded, for nighttime use, custom, each

A6587

Gradient pressure wrap with adjustable straps, foot, each

A6524

Gradient compression garment, lower leg and foot, padded, for nighttime use, each

A6588

Gradient pressure wrap with adjustable straps, arm, each

A6525

Gradient compression garment, lower leg and foot, padded, for nighttime use, custom, each

A6589

Gradient pressure wrap with adjustable straps, bra, each

A6526

Gradient compression garment, full leg and foot, padded, for nighttime use, each

A6593

Accessory for gradient compression garment or wrap with adjustable straps, non-otherwise specified

A6527

Gradient compression garment, full leg and foot, padded, for nighttime use, custom, each

A6594

Gradient compression bandaging supply, bandage liner, lower extremity, any size or length, each

A6528

Gradient compression garment, bra, for nighttime use, each

A6595

Gradient compression bandaging supply, bandage liner, upper extremity, any size or length, each

A6529

Gradient compression garment, bra, for nighttime use, custom, each

A6596

Gradient compression bandaging supply, conforming gauze, per linear yard, any width, each

A6552

Gradient compression stocking, below knee, 30-40 mmhg, each

A6597

Gradient compression bandage roll, elastic long stretch, linear yard, any width, each

A6553

Gradient compression stocking, below knee, 30-40 mmhg, custom, each

A6598

Gradient compression bandage roll, elastic medium stretch, per linear yard, any width, each

A6554

Gradient compression stocking, below knee, 40 mmhg or greater, each

A6599

Gradient compression bandage roll, inelastic short stretch, per linear yard, any width, each

A6555

Gradient compression stocking, below knee, 40 mmhg or greater, custom, each

A6600

Gradient compression bandaging supply, high density foam sheet, per 250 square centimeters, each

A6556

Gradient compression stocking, thigh length, 18-30 mmhg, custom, each

A6601

Gradient compression bandaging supply, high density foam pad, any size or shape, each

A6557

Gradient compression stocking, thigh length, 30-40 mmhg, custom, each

A6602

Gradient compression bandaging supply, high density foam roll for bandage, per linear yard, any width, each

A6558

Gradient compression stocking, thigh length, 40 mmhg or greater, custom, each

A6603

Gradient compression bandaging supply, low density channel foam sheet, per 250 square centimeters, each

A6559

Gradient compression stocking, full length/chap style, 18-30 mmhg, custom, each

A6604

Gradient compression bandaging supply, low density flat foam sheet, per 250 square centimeters, each

A6560

Gradient compression stocking, full length/chap style, 30-40 mmhg, custom, each

A6605

Gradient compression bandaging supply, padded foam, per linear yard, any width, each

A6561

Gradient compression stocking, full length/chap style, 40 mmhg or greater, custom, each

A6606

Gradient compression bandaging supply, padded textile, per linear yard, any width, each

A6562

Gradient compression stocking, waist length, 18-30 mmhg, custom, each

A6607

Gradient compression bandaging supply, tubular protective absorption layer, per linear yard, any width, each

A6563

Gradient compression stocking, waist length, 30-40 mmhg, custom, each

A6608

Gradient compression bandaging supply, tubular protective absorption padded layer, per linear yard, any width, each

A6564

Gradient compression stocking, waist length, 40 mmhg or greater, custom, each

A6609

Gradient compression bandaging supply, not otherwise specified

A6565

Gradient compression gauntlet, custom, each

A6610

Gradient compression stocking, below knee, 18-30 mmhg, custom, each

A6566

Gradient compression garment, neck/head, each

E0493

Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply

A6567

Gradient compression garment, neck/head, custom, each

E0530

Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type

A6568

Gradient compression garment, torso and shoulder, each

E0678

Non-pneumatic sequential compression garment, full leg

A6569

Gradient compression garment, torso/shoulder, custom, each

E0679

Non-pneumatic sequential compression garment, half leg

A6570

Gradient compression garment, genital region, each

E0680

Non-pneumatic compression controller with sequential calibrated gradient pressure

A6571

Gradient compression garment, genital region, custom, each

E0681

Non-pneumatic compression controller without calibrated gradient pressure

A6572

Gradient compression garment, toe caps, each

E0682

Non-pneumatic sequential compression garment, full arm

A6573

Gradient compression garment, toe caps, custom, each

E0732

Cranial electrotherapy stimulation (ces) system, any type

A6574

Gradient compression arm sleeve and glove combination, custom, each

E0733

Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve

A6575

Gradient  compression arm sleeve and glove combination, each

E0734

External upper limb tremor stimulator of the peripheral nerves of the wrist

A6576

Gradient  compression arm sleeve, custom, medium weight, each

E0735

Non-invasive vagus nerve stimulator

A6577

Gradient  compression arm sleeve, custom, heavy weight, each

E1301

Whirlpool tub, walk-in, portable

A6578

Gradient  compression arm sleeve, each

E3000

Speech volume modulation system, any type, including all components and accessories

A6579

Gradient compression glove, custom, medium weight, each

L3161

Foot, adductus positioning device, adjustable

A6580

Gradient  compression glove, custom, heavy weight, each

L5615

Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control

A6581

Gradient compression glove, each

L5926

Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type

                                   

The following codes have been removed from the Medicaid DME Authorization Grid and do not require prior authorization as of January 1, 2024:

 

K1001

Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type

K1002

Cranial electrotherapy stimulation (CES) system, includes all supplies and accessories, any type

K1005

Disposable collection and storage bag for breast milk, any size, any type, each

K1013

Enema tube, with or w/o adapter, any type, replacement only, each

K1022

Knee, hip disarticulation, positional rotation unit, any type

 

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