The following sections of the Fidelis Care authorization grids have been updated effective May 1, 2026.
The following codes have been added to the Medicaid Authorization Grid and requires 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: A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, A2040, A2041, A2042, A2043, A2044, A2045, G0681, G0682, G0683, G0684, 11200, 11201, 15271, 15274, 15275, 15276, 15734, 15769-15776, 15778-15829, 17340-17999, Q4101, Q4121, Q4186, Q4195, Q4196, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
6. Proprietary Laboratory Analysis: 0614U, 0615U, 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0628U, 0629U, 0630U
E. Imaging Studies: The services below require authorization:
5. Other: G0680
The following codes have been added to the Medicare, Essential Plan, and Ambetter Metal-Level Plans 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 require authorization for any place of service: A2025, A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, A2040, A2041, A2042, A2043, A2044, A2045, G0681, G0682, G0683, G0684, 11200, 11201, 11719, 15769 - 15829, 17340-17999, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4418, Q4419, Q4420, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4431, Q4432, Q4433, Q4435, Q4436, Q4437, Q4438, Q4439, Q4440
V. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
5. Proprietary Laboratory Analysis: 0037U, 0340U, 0600U, 0601U, 0602U, 0603U, 0604U, 0605U, 0606U, 0607U, 0608U, 0609U, 0610U, 0611U, 0612U, 0613U, 0614U, 0615U, 0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0628U, 0629U, 0630U
E. Imaging Studies: The following services require authorization:
4. Other: G0680
The following codes have been updated on the Medicaid, CHP, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization:
J1439 ferric carboxymaltose inj
The following codes have been updated on the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization as of April 1, 2026:
C9309 Onasemnogene abeparvovec-brve, Inj
C9818 Suzetrigine, oral
J1553 Immune globulin (yimmugo), Inj
J3404 Zopapogene imadenovec-drba suspension, Inj
J9003 Leuprolide injectable (camcevi etm)
J9183 Gemcitabine intravesical system
J9277 Pembrolizumab and berahyaluronidase alfa-pmph, Inj
J9601 Linvoseltamab-gcpt, Inj
Q5161 Denosumab-kyqq (aukelso/bosaya), biosimilar, Inj
Q5162 Denosumab-nxxp (bildyos/bilprevda), biosimilar, Inj
For Medicaid, Essential Plan, AmBetter Metal-Level Plans, and Medicare, the following codes have been added to the list of drugs that require NCH review as of April 1, 2026:
J9003 Leuprolide injectable (camcevi etm)
J9183 Gemcitabine intravesical system
J9277 Pembrolizumab and berahyaluronidase alfa-pmph, Inj
J9278 Carboplatin (avyxa), Inj
J9601 Linvoseltamab-gcpt, Inj
Q5161 Denosumab-kyqq (aukelso/bosaya), biosimilar, Inj
Q5162 Denosumab-nxxp (bildyos/bilprevda), biosimilar, Inj
The following codes have been added to the DME Authorization Grid and require prior authorization:
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A6548
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Accessory to custom gradient compression garment, silicone band, any size
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A8005
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Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted
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A8006
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Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only
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L2221
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Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source
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L5992
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All lower extremity prosthesis, foot shell for modular foot/non-solid ankle cushion heel (sach) replacement only
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Visit: Authorization Grids