03.09.2025
•
Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective October 1, 2025.
The following code has been added to the Medicaid DME Authorization grid and requires prior authorization for Medicaid, Medicare, Essential Plan, and Metal-Level lines of business:
L1907 Afo supramalleolar custom
The following code has been added on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
J9306 pertuzumab (Perjeta)
The following code has been added on the Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
J9308 ramucirumab (Cyramza)
The following code has been added on the Medicaid and Metal-Level Products Authorization Grids and requires prior authorization:
J9307 pralatrexate (Folotyn)
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 now require prior authorization for Fidelis Care, are listed in the chart below:
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Medicaid
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|
Code
|
Description
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15734
|
MUSCL MYOCUT/FASCIOCUT FLAP; TRUNK
|
|
19301
|
PARTIAL MASTECTOMY
|
|
19357
|
BREAST RECON IMMED/DELAY W/EXPANDR W/SUBSQT EXPA
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|
49329
|
LAPARO PROC, ABDM/PER/OMENT
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|
49505
|
PRP I/HERN INIT REDUC >5 YR
|
|
49591
|
RPR AA HERNIA 1ST < 3 CM REDUCIBLE
|
|
49593
|
RPR AA HERNIA 1ST 3-10 CM REDUCIBLE
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|
49595
|
RPR AA HERNIA 1ST > 10 CM REDUCIBLE
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|
49650
|
LAP ING HERNIA REPAIR INIT
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|
58571
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TLH W/T/O 250 G OR LESS
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|
58573
|
TLH W/T/O UTERUS OVER 250 G
|
|
58661
|
LAPAROSCOPY, REMOVE ADNEXA
|
|
58662
|
LAPAROSCOPY W/FULGURATION OR EXCISION OF LESIONS OF OVARY
|
|
59841
|
INDUCED AB BY DILAT & EVACUATION
|
|
81220
|
CFTR GENE COM VARIANTS
|
|
93656
|
TX ATRIAL FIB PULM VEIN ISOL
|
|
A0430
|
AMB SRV CONV AIR TRANS 1W FIX WING
|
|
A0431
|
AMB SVC AIR TRNSPRT 1 WY ROT
|
|
A0435
|
FIXED WING AIR MILEAGE P/STATUTE MI
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|
A0436
|
ROTARY WING AIR MILEAGE-STATUT MILE
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|
A4239
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SPLY ALW NONADJUNC NONIMPL CGM 1 MO SPLY= 1 UOS
|
|
C1767
|
GENERATOR, NEUROSTIMULATOR (IMPLANTABLE)
|
|
G0480
|
DR TST DEFIN DR ID M P D 1-7 DR CL
|
|
Q4101
|
APLIGRAF PER SQ CM
|
|
Q4121
|
THERASKIN PER SQ CM
|
|
Q4186
|
EPIFIX PER SQ CM
|
|
Q4195
|
PURAPLY PER SQ CM
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|
Q4196
|
PURAPLY AM PER SQ CM
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|
Q5002
|
HOSPICE/HHC PROV ASSTD LIVIN
|
|
K0001
|
STANDARD WHEELCHAIR
|
|
Essential Plan and Metal-Level Products
|
|
Code
|
Description
|
|
28300
|
INCISION OF HEEL BONE
|
|
28308
|
INCISION OF METATARSAL
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|
43281
|
LAP PARAESOPHAG HERN REPAIR
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|
43282
|
LAP PARAESOPH HER RPR W/MESH
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|
49329
|
LAPARO PROC, ABDM/PER/OMENT
|
|
55866
|
LAPARO RADICAL PROSTATECTOMY
|
|
28285
|
CORRECT HAMMERTOE
|
|
28299
|
CORRECTION HALLUX VALGUS
|
|
88377
|
M/PHMTRC ALYS ISHQUANT/SEMIQ
|
|
L5856
|
ADD LOW EXT PROS KNEE-SHIN SYS SWING&STANCE PHSE
|
|
Medicare
|
|
Code
|
Description
|
|
A0431
|
AMB SVC AIR TRNSPRT 1 WY ROT
|
|
A0436
|
ROTARY WING AIR MILEAGE-STATUT MILE
|
|
19303
|
MASTECTOMY, SIMPLE, COMPLETE
|
|
58571
|
TLH W/T/O 250 G OR LESS
|
|
58573
|
TLH W/T/O UTERUS OVER 250 G
|
|
58661
|
LAPAROSCOPY, REMOVE ADNEXA
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