Fidelis Care Authorization Grids Effective December 1, 2025
10/31/2025
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Posted by Provider Relations
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Provider News
The following sections of the Fidelis Care authorization grids have been updated effective December 1, 2025.
The following code has been added to the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
6. Proprietary Laboratory Analysis - 0340U
The following code has been added on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
S0013 esketamine (Spravato)
The following has been updated on the Metal-Level Products Authorization Grid:
The Pharmacy section of the Metal-Level Authorization Grid has been updated to include an indicator for drugs that have a site of care authorization criteria.
In addition to the changes listed above, Fidelis Care would like to share some important updates to our prior authorization requirements effective October 1, 2025. These changes are aligned with broader industry efforts, driven by commitments to regulatory agencies and America’s Health Insurance Plans (AHIP), to modernize and streamline prior authorization.
A full list of code changes that no longer require prior authorization for Fidelis Care, are listed in the charts below:
| Medicaid |
| Code | Description |
| 11900 | INJ INTRALES; UP TO & INCL 7 LES |
| 15777 | ACELLULAR DERM MATRIX IMPLT |
| 36471 | INJ SCLEROSING SOLUTION; MX VEINS SAME LEG |
| 36479 | ENDOVENOUS LASER VEIN ADDON |
| 81244 | FMR1 GENE CHARACTERIZATION |
| 81331 | SNRPN/UBE3A GENE |
| 99601 | HOME INFUSION/VISIT, 2 HRS |
| 99602 | HOME INFUSION EACH ADDTL HR |
| A6549 | GRADIENT COMP STOCKING/SLEEVE NOS |
| E0441 | STATIONARY O2 CONTENTS, GAS |
| E0951 | HEEL LOOP/HOLDER, WITH OR WITHOUT ANKLE STRAP, EACH |
| E0952 | TOE LOOP/HOLDER, EACH |
| E0960 | WHEELCHAIR/SHOLDER HARNESS/STRAPS/CHEST STRAP/INCL ANY TYPE MNTNG HRDWR |
| E0961 | MNL WC ACCESS WHL LOCK BRAKE |
| E0973 | WHEELCHAIR ADJUSTABLE HEIGHT, DETACH ARMREST, CMPLTD ASSEMBLY |
| E0978 | WHEELCHAIR ACCESSORY, SAFETY BELT/ PELVIC STRAP, EACH |
| E1392 | PORTABLE OXYGEN CONCENTRATOR |
| E2211 | MANUAL WHEELCHAIR ACCESSORY PNEUMATIC PROPULSION TIRE ANY SIZE |
| E2213 | MANUAL WHEELCHAIR ACCESS INSERT FOR PNEUM PROPULSION TIRE REMOVABLE |
| E2231 | SOLID SEAT SUPPORT BASE |
| E2366 | PWR WC ACSS BATTRY CHARGER 1 |
| K0019 | ARM PAD REPLACEMENT ONLY EAC |
| K0038 | LEG STRAP EA |
| K0043 | FOOTREST LWR EXT TUBE REPL ONLY EA |
| K0739 | REPAIR/SVC DME NON-OXYGEN EQ |
| S5501 | HOME INFUS TX CATH CARE COMP |
| S9494 | HIT ANTIBIOTIC/ANTIFUNGAL; D |
| S9500 | HIT ANTIBIOTIC/ANTIFUNGAL; Q |
| S9502 | HIT ABX ANTIVIRL/ANTIFUNGAL; |
| Marketplace |
| Code | Description |
| 11900 | INJ INTRALES; UP TO & INCL 7 LES |
| 36476 | ENDOVEN ABLAT TX VEIN EXT RF; 2&>VNS 1 EXT EA |
| 81244 | FMR1 GENE CHARACTERIZATION |
| K0739 | REPAIR/SVC DME NON-OXYGEN EQ |
| S9127 | SOCIAL WORK VISIT THE HOME |
| Medicare |
| Code | Description |
| 36471 | INJ SCLEROSING SOLUTION; MX VEINS SAME LEG |
| 37765 | STAB PHLEBECT VV 1 EXT 10-20 INCI |
| 37766 | STAB PHLEBECT VV 1 EXT >20 INCI |
| 95805 | MX SLEEP LATENCY TEST-MX TRIALS-ASSESS SLEEPINES |
| E0954 | WHEELCHAIR AC FOOT BOX ANY TY EA FT |
| E0956 | WHEELCHAIR/LATERAL TRUNK, HIP SUPPORT, PREFBRCTD, INCL FIXED MNTNG HRDWR |
| E2209 | ACCESSORY, ARM TROUGH, W OR W/OUT HAND SUPPORT, EACH |
| E2210 | WC ACESS BEARINGS ANY TYPE |
| E2365 | PWR WC ACSS U-1 SEALED BATTR |
| E2366 | PWR WC ACSS BATTRY CHARGER 1 |
| E2603 | SKN PROTCT WC SEAT WDTH |
| E2615 | PSTN WC BACK CUSHN POSTLAT WIDTH < 22 IN ANY HT |
| G0156 | HHCP-SVS OF AIDE, EA 15 MIN |
| K0019 | ARM PAD REPLACEMENT ONLY EAC |
| K0052 | SWNGAWAY DTACHBLE FTRSTS RPL |
| K0733 | PWR WC 12-24 AMP HR LEAD BAT |
| K0739 | REPAIR/SVC DME NON-OXYGEN EQ |
Visit: Authorization Grids