Fidelis Care Authorization Grids Effective September 1, 2025
7/30/2025
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Posted by Provider Relations
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Provider News
The following section of the Fidelis Care authorization grids have been updated effective September 1, 2025.
The following code has been updated on the Essential Plan and Metal-Level Products Authorization Grids:
- Durable Medical Equipment/Supplies:
1. These DME codes do not require an authorization: A7046
The following codes have been updated on the Medicare Authorization Grid:
A. Durable Medical Equipment/Supplies:
1. These DME codes do not require an authorization: A4557, A5500, A6530, A7046, E0443, E0730, E0849, E0951, E0955, E0956, E0961, E0971, E0973, E0990, E1392, E2210, E2365, E2601, E2607, E2624, K0001, K0019, K0040, K0195, K0738, L5685
2. The following orthotic codes do not require an authorization: L2820, L3908
F. Therapeutic Services:
2. Pain Management Codes (i.e. injections, TENS, therapeutic services): Removed codes 20550 and 20551
I. Outpatient and DME Services:
A. Diagnostic Testing:
1. Sleep Studies, including Home Sleep Studies
** 95806 does not require authorization
Visit: Authorization Grids