The following sections of the Fidelis Care authorization grids have been updated effective March 1, 2026.
The following codes have been added to the Medicaid, Medicare, Essential Plan, and Qualified Health Plan Authorization Grids and require prior authorization:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures:
· Only the following codes continue to require authorization for any place of service: Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433
K. Vascular procedures (i.e. vein stripping, ligation, ablation and sclerotherapy): 47384, 55877
M. Spinal Surgery: 62330, 62380, 63032
R. Other: 27458, 27713, 52443, 64654, 64655, 64656, 64728
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
4. Gastroenterology Procedures
· Authorization is required for 43290 and 43889 when performed in any place of service
5. Proprietary Laboratory Analysis: 0340U, 0493U, 0600U, 0601U, 0602U, 0603U, 0604U, 0605U, 0606U, 0607U, 0608U, 0609U, 0610U, 0611U, 0612U, 0613U
6. Other services: G0330, G0571, 42975, 64567, 87182, 87183, 97037
E. Imaging Studies: The services below require authorization:
5. Other: 75577
The following codes have been added to the Medicare Authorization Grid and require prior authorization:
II. Outpatient surgery: The following services require prior authorization:
P. Urology: 55868, 55869
IV. Outpatient and DME Services: These services require prior authorization:
B. Durable Medical Equipment:
1. The following DME codes do not require an authorization: E0246
Visit: Authorization Grids