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​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Services that require precertification for AmeriHealth Pennsylvania Members (Effective 10/01/2025)​

Services that R​equire Precertification 


As of October 1, 2025, this list applies to all AmeriHealth Pennsylvania HMO and POS products, including Flex products

This applies to services performed on an elective, nonemergency basis 

Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded. 

You can find additional information regarding preapproval/precertification, member cost-sharing and prescription drug coverage on the AmeriHealth Preapproval/Precertification Requirements and Member Cost-Sharing page. 

All Home-Care Services (including Infusion Therapy in the Home) 


Inpatient Services 


  • Acute rehabilitation admissions 
  • Elective surgical and nonsurgical inpatient admissions 
  • Inpatient hospice admissions 
  • Long term acute care (LTAC) facility admissions
  • Skilled nursing facility admissions​

Cardiology Procedure​​​s


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable.  For additional information, refer to the current version of Medical Policy 11.02.27, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound.

Arterial Ultrasound

​93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931


​Diagnostic Coronary Angiography

​93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553, C7557, C7562


Percutaneous Coronary Intervention

​92920, 92924, 92928, 92933, 92937, 92943, C9600, C9602, C9604, C9607

​ Proce​​​dures
  • Cochlear Implant Surgery and Associated Supplies/Bone-Anchored (Osseointegrated) Hearing Aids, Implantable Bone Conduction Hearing Aids

    69714, 69715, 69717, 69718, 69930, L8614, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693  

  • Obesity Surgery

    43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774,43775, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999  


Musculoskeletal ​​Procedures

Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 00.01.66, Musculoskeletal Services.​

Allograft

​29032, 29033, 29034

Bone Grafts

​20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938

Bone Growth Stimulator

​E0748

Cervical Spine Surgery - Anterior Decompression with Fusion

​22551, 22552, 22554, 22830, 22585, 63081, 63082

Cervical Spine Surgery - Anterior Decompression without Fusion

​63075, 63076

Cervical Spine Surgery - Posterior Decompression with Fusion

​22600, 22614, 22632, 22634, 22830, 22864

Cervical Spine Surgery - Posterior Decompression without Fusion

​63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63052, 63053

Cervical Total Disc Replacement (Arthroplasty)

​0095T, 0098T, 22856, 22858, 22861, 22864

Hip Arthroscopy

​27120, 27122, 29860, 29861, 29862, 29863, 29914, 29915, 29916

Hip Replacement

​27125, 27130, 27132, 27134, 27137, 27138, S2118

Knee Arthroscopy

​29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Knee Open

​27331, 27332, 27333, 27334, 27335, 27345, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429

Knee Replacement

​27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, J7330, S2112

Lumbar Decompression (Laminotomy/Laminectomy/Discectomy/Formanitomy)

​63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, S2350, S2351

Lumbar Disc Replacement (Arthroplasty)

​0164T, 0165T, 22857, 22860, 22862, 22865

Lumbar Fusion

​22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22830

Sacroiliac Joint Fusion

​27279, 27280, C1737

Shoulder - Arthroscopic and Open Procedures

​23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828

Shoulder Replacement

​23470, 23472, 23473, 23474

Spinal Deformity (Scoliosis/Kyphosis)

​22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22610, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308

Spinal Instrumentation

​22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859

Vertebroplasty, Kyphoplasty

​22510, 22511, 22512, 22513, 22514, 22515, C7504, C7505, C7507, C7508

Interventional Pain Manageme​​nt Services


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 00.01.66, Musculoskeletal Services.​
Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks

  • Cervical or Thoracic Epidural Steroid Injection
62320, 62321, 64479, 64480​

  • Lumbar or Sacral Epidural Steroid Injection
62322, 62323, 64483, 64484

Paravertebral Facet Injection/Nerve Block/Neurolysis

  • Cervical or Thoracic Facet Injection
​64490, 64491, 64492

  • Cervical Radiofrequency Ablation
​64633, 64634

  • Lumbar or Sacral Facet Injection
​64493, 64494, 64495

  • Lumbar Radiofrequency Ablation
​64635, 64636


Sacroiliac Joint injections

​27096, G0260

Spinal Cord and Nerve Root Stimulators

  • Implantation of Spinal Cord Stimulators
​63650, 63655, 63663, 63664, 63685, 63688


Regional Sympathetic Nerve Blocks

​64510, 64520


Reconstructive Procedures and Poten​​tially Cosmetic Procedures 


  • Blepharoplasty/Ptosis Repair

    15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909​ 

  • ​Bone Graft, Genioplasty and Mentoplasty

    21120, 21121, 21122, 21123
     
  • Breast Reconstruction

    11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15771, 15772, 15773, 15774, 15777, 19300, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4116, Q4130, Q4142, Q4143, S2066, S2067, S2068
     
  • Breast Reduction

    15877, 19318
     
  • Breast Augmentation/Mammoplasty

    19325​
     
  • Breast Mastopexy

    19316
     
  • Insertion of Breast Implants

    19340, 19342, 19396
     
  • Removal of Breast Implants

    19328, 19330, 19370, 19371
     
  • Canthopexy/Canthoplasty

    21280, 21282, 67950
     
  • Cervicoplasty

    17999
     
  • Chemical Peels

    15788, 15789, 15792, 15793​
     
  • Dermabrasion

    15780, 15781, 15782, 15783
     
  • Excision of Excessive Skin and/or Subcutaneous Tissue

    15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839
     
  • Gender Affirming Interventions 

    11920, 11921, 11922, 11960, 15877, 17380, 19303, 53430,​​​54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
     
  • Genetically and Bio-Engineered Skin Substitutes for Wound Care
    A2001, A2002, A2004, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021,​A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2030, A2031, A2032, A2033, A2034, A2035, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4199, Q4205, Q4206, Q​​4208, Q4209, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4228, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279,​Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q​​4308, Q4309, Q4310, Q4311, Q4312, Q4314, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, ​Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4344, ​Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382   
    ​
     
  • Gynecomastia
​​19300

  • Hair Transplant

    15775, 15776
     
  • Injectable Dermal Fillers
​​Effective 07/01/2023, procedure codes that represent Injectable Dermal Fillers (11950, 11951, 11952, 11954, Q2026, and Q2028) no longer require precertification for Independence Commercial Lines of Business.

  • Keloid Removal

    13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
     
  • Lipectomy, Liposuction, or Any Other Excess Fat-Removal Procedure

    15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879
     
  • Otoplasty

    13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399
     
  • Rhinoplasty

    30400, 30410, 30420, 30430, 30435, 30450
     
  • Rhytidectomy

    15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876
     
  • Scar Revision

    13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
     
  • Skin Closures

    13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770
     
  • Surgery for Varicose Veins, Including Perforators and Sclerotherapy
​​​36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202

​Day Rehabilitation Programs​


​0931, 0932​

Elective (Nonemergency) Gr​​​ound, Air, and Sea Ambulance Transportation


A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961 


Outpatient Private-Duty Nu​rsing


S9123, S9124 


Day Rehabilitation Progr​​ams


0931, 0932 
​

Outpatient Radiation ​​Therapy


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA09.002, High-Technology Radiology Services.

​
Brachytherapy

​0394T, 0395T, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 77789, G0458
​
Cardiac Focal Ablation

​0747T

Hyperthermia Treatment

77600, 77605, 77610, 77615, 77620

Image-Guided Radiation (IGRT)

​77014, 77387, G6001, G6002, G6017

Intensity Modulated Radiation Therapy (IMRT)

​77385, 77386, G6015, G6016

Intraoperative Radiation Therapy (IORT)

​77424, 77425

Neutron Beam Radiation Therapy

​77423

Proton Beam Radiation Therapy

​77520, 77522, 77523, 77525

Radiation Treatment Delivery

​77401, 77402, 77407, 77412, A9609, G0563, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014

Stereotactic Radiation Therapy

​77371, 77372, 77373, G0339, G0340

Therapeutic Radiopharmaceuticals

​​77750, 79005, 79101, 79403, A9513, A9543, A9590, A9606, A9607, A9699, C2616, S209​

Radiology


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA09.002, High-Technology Radiology Services.


Computed Tomography (CT)

  • ​​​Abdomen
74150, 74160, 74170

  • ​​​Abdomen and Pelvis
74176, 74177, 74178

  • ​Cervical Spine
72125, 72126, 72127

  • ​Chest
71250, 71260, 71270

  • ​Head
0042T, 70450, 70460, 70470

  • ​Lower Extremity
73700, 73701, 73702

  • ​Lumbar Spine
72131, 72132, 72133

  • ​Lung
71271

  • ​Neck
70490, 70491, 70492

  • ​Orbit
70480, 70481, 70482

  • ​Pelvis
72192, 72193, 72194

  • ​Sinus
70486, 70487, 70488

  • ​Thoracic Spine
72128, 72129, 72130

  • ​Upper Extremity
73700, 73701, 73702

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET)/Computed Tomography (CT)

  • ​Computed Tomography (CT) Heart for Calcium Scoring
75771

  • ​Coronary Computed Tomography (CT) and Computed Tomography Angiography (CTA)
0503T, 75572, 75573, 75574, 75580

  • ​Tumor Imaging
78811, 78812, 78813, 78814, 78815, 78816

​​Computed Tomography Angiography (CTA)

  • ​Abdomen
74175

  • ​Abdomen and Pelvis
74174

  • ​Abdominal Arteries
75635

  • ​Chest
71275

  • ​Head
70496

  • ​Lower Extremity
73706

  • ​Lung
71271

  • ​Neck
70498

  • ​Pelvis
72191

  • ​Upper Extremity
73206

​CT Heart for Calcium Scoring

75571


​Diagnostic Computed Tomography (CT) Colonoscopy

74261, 74262


​Fluorine-18 fluorodeoxyglucose (f-18 FDG)

S8085


​Follow Up Study Computed Tomography (CT)

76380


​Functional Magnetic Resonance Imaging (MRI) Brain

70554, 70555


​Low-Field MRI

S8042

Magnetic Resonance Angiography (MRA)

  • ​Abdomen
74185, C8900, C8901, C8902

  • ​Chest
71555, C8909, C8910, C8911

  • ​Head
615, 70544, 70545, 70546

  • ​Lower Extremity
73725, C8912, C8913, C8914

  • ​Neck
615, 70547, 70548, 70549

  • ​Pelvis
72198, C8918, C8919, C8920

  • ​Spinal Canal
72159, C8931, C8932, C8933

  • ​Upper Extremity
73225, C8934, C8935, C8936

​Magnetic Resonance Elastograhpy

76391

Magnetic Resonance Imaging (MRI)

  • ​Abdomen
74181, 74182, 74183, S8037

  • ​Bone Marrow
77084

  • ​Brain
70551, 70552, 70553

  • ​Breast
77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908

  • ​Cardiac
75557, 75559, 75561, 75563, 75565, C9762, C9763

  • ​Cervical Spine
72141, 72142, 72156

  • ​Chest
71550, 71551, 71552

  • ​Fetal
74712, 74713

  • ​Lower Extremity
73718, 73719, 73720, 73721, 73722, 73723

  • ​Low Field MRI
S8042

  • ​Lumbar Spine
72148, 72149, 72158

  • ​​Orbit
70540, 70542, 70543

  • ​​Pelvis
72195, 72196, 72197

  • ​Temporomandibular Joint (TMJ)
70336

  • ​Thoracic Spine
72146, 72147, 72157

  • ​Upper Extremity (Any Joint)
73221, 73222, 73223

  • ​​Upper Extremity (Non-Joint)
73218, 73219, 73220

​Magnetic Resonance Spectroscopy (MRS)

76390


​Magnetic Resonance Technology (MRT)

616

Magnetoencephalography (MEG)

  • Head

​95965, 95966*


Nuclear Cardiology

  • ​Cardiac Blood Pool Imaging
78472, 78473, 78481, 78483, 78494, 78496

  • ​Infarct Imaging
0742T, 78451, 78452, 78453, 78454, 78466, 78468, 78469

Positron Emission Tomography (PET)

  • ​Brain Imaging
78608, 78609

  • ​Myocardial Imaging
78429, 78430, 78431 78432, 78433, 78434, 78459, 78491, 78492

  • Other Imaging Services
404

​Quantitative Computed Tomography (QCT) Bone Densitometry

77078

​Resting Transthoracic Echocardiography (TTE)

93303, 93304, 93306, 93307, 93308

  • ​Echocardiography Add-On Codes
93319, 93320, 93321, 93325, 93352

​Screening Computed Tomography (CT) Colonoscopy

74263

​Stress Echocardiography

93350, 93351

  • ​Echocardiography Add-On Codes
93320, 93321, 93325, 93352

​Transesophageal Echocardiography (TEE)

93312, 93313, 93314, 93315, 93316, 93317

  • ​Echocardiography Add-On Codes
93319, 93320, 93321, 93325

3-D Rendering

  • ​Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Grouping
76376, 76377​

* Precertification for these codes will become effective November 15, 2025.

Prosthetics/Orthoses​​​: 


  • Custom Ankle-Foot Orthoses

    L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631​
     
  • Custom Knee-Ankle-Foot Orthoses

    L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128
     
  • Custom Knee Braces

    L1834, L1840, L1844, L1846, L1860
     
  • ​Custom Limb Prost​hetics Including Accessories/Components
L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6050, L6055, L6100, L6110, L6120, L6130, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6700, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7406, L7499, L5657, L6034, L6035, L6036, L6038​
​

Selected Durable Medi​​​​cal Equipment (DME) 


  • Bone Growth Stimulators

    Low-Intensity Ultrasound Noninvasive Bone Growth Stimulation
    E0760

    Other Than Spinal Noninvasive Electrical Bone Growth Stimulation
    E0747

    Spinal Noninvasive Electrical Bone Growth Stimulation
    E0748

  • Bone-Anchored (Osseointegrated) Hearing Aids

    69716, 69719, 69726, 69727, L8690, L8691, L8692, L8693, L8694
     
  • Continuous Positive Airway Pressure (CPAP) Devices, Bi-Level (Bi-PAP) Devices, and All Supplies

    Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 07.03.05, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.

​A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0561, E0562, E0601, E1399
​
  • Dynamic Adjustable and Static Progressive Stretching Devices (excludes CPMs)

    E1800, E1802, E1805, E1810, E1812, E1825, E1830
     
  • Electric, Power, and Motorized Wheelchairs Including Custom Accessories

    E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630 K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898
     
  • Insulin Pumps

    E0784, E0787, S1034
     
  • Manual Wheelchairs with the Exception of those that are Rented

    E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060,​E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110  E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222  E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270  E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608  E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628  E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108
     
  • Negative Pressure Wound Therapy

    A6550, A9272, E2402, K0743, K0744, K0745, K0746
     
  • Neuromuscular Stimulators

    E0744, E0745, E0764, E0770
     
  • Power Operated Vehicles (POV)

    E1230, K0800, K0801, K0802, K0812
     
  • Pressure Reducing Support Surfaces Including: 

    • Air Fluidized Bed

      E0194
       
    • Non Powered Advanced Pressure Reducing Mattress

      E0371, E0373
       
    • Powered Air Flotation Bed (Low Air Loss Therapy)

      E0193, E0372
       
    • Powered Pressure Reducing Mattress

      E0277 

  • Push Rim Activated Power Assist Devices

    E0986
     
  • Repair or Replacement of All DME Items, as well as Orthoses and Prosthetics that Require Precertification - See specific DME, orthoses, and prosthetics categories for Repair or Replacement codes that require precertification.
     
  • Speech Gen​erating Devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336
 

Medica​​​​l Foods​


B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435 


Hyperbaric Oxygen Therapy


0413, G0277 


In-Lab / Facility Sleep Studies


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 07.03.05, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies

All Transplant Procedures, with the Exception of Corneal Tra​nsplants


​0584T, 0585T, 0586T, 15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150  


Mental Health/Serious Mental Illness/Substa​​nce Abuse

 
  • Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs) 

  • Repetitive transcranial magnetic stimulation (rTMS) 
​​0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869​

  • ​Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs) 


Autism Spectrum Diso​​​rders 


  • Applied behavioral analysis

​0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
​

Genetic and Genomic Tests Requiring ​​​Precertification


Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 06.02.52, eviCore Lab Management Program.​

The following list is a guide to the types of genetic and genomic tests that require precertification. 
​

Hereditary Cancer Syndrom​es 


  • BRCA gene testing (breast and ovarian cancer syndrome) 
  • Lynch syndrome gene testing 
  • Familial adenomatous polyposis gene testing 
  • PTEN gene testing (Cowden syndrome) 
  • ​General cancer type panels (such as colon, breast, or neuroendocrine cancers) 

Hereditary Heart Dis​​eases 


  • Long QT syndrome gene testing 
  • ​Aortic dilation or a​neurysm syndrome testing (includes Marfan syndrome) ​

Other Full Gene An​​alysis Testing 


  • Cystic fibrosis full gene sequencing and deletion/duplication analysis 
  • ​PMP22 full gene sequencing and deletio​n/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy) 


Tests for Many Genetic Disorders Simultane​​ously 


  • Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening) 
  • Hearing loss panels 
  • Intellectual disability panels 
  • Noonan spectrum diso​rders panels 

Specialty Onc​​​​ology Tests


  • Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™) 
  • Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others) 
  • Tissue of origin testing (for cancer of unknown primary) 
  • ​PCA3 testing for prostate cancer 

Pharmacogenomic Tes​​ts 


  • Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19) 
  • Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGTSM) 
  • Warfarin response testing 
  • ​MGMT methylati​on analysis for glioblastoma 


Other Specialty​​​ Tests 


  • Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6) 
  • ​Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR) 


Geno​​​me-Wide Tests 


  • Microarray studies 
  • Whole exome testing 
  • Whole genome testing 
  • ​Mitochondrial genome or nuclear testing 


ANY genetic test for more than one gene or c​​​ondition (often includes words like “panel" or “comprehensive" in the name) 


ANY genetic test that will be billed with a ​​Non-Specific Procedure Code 


  • Billed with CPT® codes 81400-81408 
  • Billed with an unlisted code: 81479, 81599, 84999

The following are the specific CPT and HCPCS codes for genetic and genomic tests that require pre-service reviews by CareCore National, LLC d/b/a eviCore healthcare (eviCore).


​​Molecular Pathology

0001U, 0005U, 0016U, 0017U, 0018U, 0019U, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0297U, 0298U, 0299U, 0300U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U, 0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0488U, 0489U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0501U, 0506U, 0507U, 0508U, 0509U, 0510U, 0516U, 0532U, 0533U, 0534U, 0536U, 0537U, 0538U, 0539U, 0540U, 0543U, 0544U, 0549U, 81162, 81163, 81164, 81165, 81166, 81167, 81173, 81174, 81185, 81186, 81189, 81190, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81493, 81518, 81522, 81523, 81542, 81552


​Molecular HCPCS Codes

G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S3861, S3865, S3866, S3870


​Multianalyte Assays with Algorithmic Analyses (MAAA)

0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0017M, 0020M, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0444U, 0523U, 0529U, 0530U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 81195, 81504, 81519, 81520, 81521, 81525, 81529, 81540, 81541, 81546, 81551, 81554, 81558, 81595


​Unlisted Molecular Codes (When Reported With Genetic/Genomic Testing)

81479, 81599, 84999​


Specialty Drugs Requiring Pr​ecertification


All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change. 


Amyotrophic Lateral Sclerosis Agents


  • NurOwn® - J3490, J3590, and C9399​


Antineoplastic Ag​​ents 


  • Abraxane® - J9264
  • Adstiladrin® - J9029​
  • Adcetris® - J9042
  • Anktiva® - J9028
  • Alymsys® - Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)​​
  • Avastin® - C9257, J9035, and Q5129 (Note: Ophthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Avzivi® - J3490, J3590, and C9399​
  • Azedra®​* - A9590
  • Bizengri® - J9382​
  • Blincyto™ - J9039
  • Columvi™ - J9286​
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ – J9144
  • Datroway® - J9011
  • Elahe​re™ - J9063
  • ​Elrexfio™ - J1323​
  • Emrelist™ - C9306 and J3590​
  • Enhertu® - J9358
  • Epkinly™ - J9321​
  • Erbitux® - J9055
  • Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Herceptin® Hylecta - J9356
  • Herzuma® - Q5113​
  • ​Imjudo® - J9347​
  • Kadcyla® - J9354
  • Kimmtrak® - J9274
  • Kyprolis® - J9047
  • Lunsumio™ - J9350​
  • Margenza™ - J9353
  • Monjuvi® - J9349​​
  • Ogivri™ - Q5114
  • Ontruzant® - Q5112
  • Opdualag™ - J9298
  • Padcev™- J9177
  • ​Patritumab deruxtecan - J3490, J3590, and C9399​
  • Pemfexy™ - J9304
  • Perjeta® - J9306
  • Phesgo™​ – J9316
  • Pluvicto™* - J3490 and C9399​
  • Polivy™ - J9309
  • Poteligeo® - J9204
  • Provenge® - Q2043
  • Riabni™ - Q5123
  • Rituxan® - J9312 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Rituxan Hycela™ - J9311
  • Rybrevant™ – J9061​
  • Rylaze™ - J9021​
  • Rytelo™ - J0870​
  • Sarclisa® - J9227
  • Taclantis (pending FDA approval) - J3490 and C9399
  • Talvey™ - J3055
  • Tecvayli™ - J9380 
  • ​Tivdak™ - J9273
  • Trodelvy® - J9317
  • Vyloy® - J1326
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ ​ – J9223
  • Zevalin®* - A9543
  • Ziihera® - J9276
  • Zynlonta™ J9359
    •  
    * Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable.​


Anti PD-1/PD-L1 Human Monoclonal Antibodies


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 
​
  • Bavencio® - J9023
  • Camrelizumab (pending FDA approval) - J3490, J3590, and C9399
  • Imfinzi™ - J9173
  • Jemperli™ - J9272
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Loqtorzi™ - J3263​
  • Opdivo® - J9299
  • Opdivo Qvantig™ - J9289
  • Tecentriq™ - J9022​
  • Tecentriq Hybreza™ - J9024​
  • Unloxcyt™ - J9275​
  • Tevimbra® - J9329​
  • Zynyz™ - J9345​
    • ​

Bone-Modifying A​​gents 


  • Bomyntra® and Conexxance® - Q5158
  • Evenity™ - J3111
  • Jubbonti® - Q5136
  • Ospomyv™ and Xbryk - Q5159
  • Prolia® - J0897
  • Stoboclo® and Osenvelt® - Q5157
  • Wyost® - Q5136​
  • ​Xgeva® - J0897 

Botulinum Toxin Agent​​s 


  • ​Botox® - J0585 ​

Chimeric Antigen Receptor (CAR-T) Thera​​pies


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  

  • Abecma® - Q2055
  • Aucatzyl® - Q2058​​
  • ​Breyanzi® - Q2054
  • Carvykti™ - Q2056
  • Kymriah™ - Q2042
  • Tecartus™ - Q2053​
  • ​Yescarta™ - Q2041 
  • ​​Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 38228

Endocrine/M​​etabolic Agents ​

​​

  • Acthar® Gel - J0801 and J0802​
  • lanerotide - J1932
  • Lutathera®* - A9513 and A9699
  • Sandostatin® LAR - J2353
  • Somatuline® depot - J1930 
  • Xenpozyme™ - J0218

* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable.​​


Enzyme Replacement Agen​​​ts


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  
  • Aldurazyme® - J1931
  • Adzynma - J7171​
  • Brineura™ - J0567
  • Cerezyme® - J1786
  • Cinaxadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399
  • Cipaglucosidase Alfa (pending FDA approval) – J3490, J3590, and C9399​
  • Elaprase® - J1743
  • Elelyso® - J3060
  • Elfabrio® - J2508​
  • Fabrazyme® - J0180
  • Kanuma® - J2840
  • Lamzede® - J0217​
  • Lumizyme® - J0221
  • Mepsevii™ - J3397
  • Naglazyme® - J1458
  • Nexviazyme™ - J0219
  • Pombiliti™ - J1203​
  • Replagal® (pending FDA approval) - J3490  
  • Revcovi™ - J3590 and C9399
  • Vimizim™ - J1322​
  • ​Vpriv® - J3385​
  • Xenpozyme® - J3590 and C9399​

Gene Replacement / Gene Editing Therapies

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit
year.
​
  • Casgevy™ - J3392
  • ​Eladocagene exuparvovec - J3490, J3590, and C9399​
  • Elevidys® - J1413
  • Hemgenix® - J1411​
  • Lenmeldy™ - J3391​
  • Luxturna™ - J3398​
  • Lyfgenia™ - J3394
  • ​Marnetegragene aututemcel - J3490, J3590, and C9399
  • Roctavian® - J1412​
  • Skysona® - J3590 and C9399​
  • Vvjuvek™ - J3401​
  • ​Zevaskyn™ - C9399 and J3590​
  • Zolgensma® - J3399
  • ​Zynteglo® - J3393


Hemophilia/Coagulation Fac​​tors


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  
  • Advate® - J7192
  • Adynovate® - J7207
  • Afstyla® - J7210
  • Alhemo® - J7173​
  • Alphanate® - J7186
  • Alphanine SD® - J7193
  • Alprolix® - J7201
  • Altuviiio™ - J7214​
  • Bebulin VH® - J7194
  • Benefix® - J7195
  • Coagadex® - J7175
  • Corifact® - J7180
  • Eloctate® - J7205
  • Esperoct® - J7204
  • Feiba NF® - J7198
  • Feiba VH® - J7198
  • Fibryga® - J7177
  • Helixate FS® - J7192
  • Hemlibra® - J7170
  • Hemofil-M® - J7190
  • Humate-P® - J7187
  • ​Hympavzi™ - J7172​
  • Idelvion® - J7202
  • Ixinity® - J7213
  • Jivi® - J7199 and J7208
  • Koate-DVI® - J7190
  • Kogenate FS® -J7192
  • Kovaltry® - J7207 and J7211
  • Monoclate-P® - J7190
  • Mononine® - J7193
  • Novoeight® - J7182
  • Novoseven RT® - J7189
  • Novoseven® - J7189
  • Nuwiq® - J7209
  • Obizur® - J7188
  • Profilnine SD® - J7194
  • Qfitlia™ - J7174​
  • Rebinyn® - J7203
  • Recombinate®​ - J7192
  • RiaSTAP® - J7178
  • Rixubis® - J7195 and J7200
  • Sevenfact® – J7212
  • Tretten® - J7181
  • Vonvendi® - J7179 and J7199
  • Wilate® - J7183
  • ​Xyntha® - J7185 


Hyaluronate Acid​​​ Products 


  • Cingal (pending FDA approval) - J3490
  • Durolane® - J7318
  • Euflexxa™ - J7323
  • Gel-One® - J7326
  • Gelsyn-3™ - J7328
  • GenVisc 850® - J7320
  • Hyalgan® - J7321
  • Hymovis® - J7322
  • Supartz® - J7321
  • Synojoynt™ - J7331
  • Triluron™ - J7332
  • TriVisc™ - J7329
  • ​VISCO-3® - J7321


Immunologica​​l Agents 


  • Actemra® - J3262 (See note below.)
  • Avtozma® - Q5156​
  • Benlysta® IV - J0490
  • ​Cosentyx® IV – J3247​
  • Entyvio™ - J3380 (See note below.)
  • Ilumya™ - J3245​
  • Imuldosa® - Q5098​
  • Omvoh™ - J2267​
  • Orencia® IV- J0129
  • ​Otulfi® - Q9999​
  • Pyzchiva® - Q9996 and Q9997
  • Saphnelo™ - J0491
  • Selarsdi™ - Q9998
  • Simponi® Aria - J1602
  • Skyrizi® IV - J2327
  • Spevigo® - J1747
  • Stelara® - J3357 and J3358  
  • Steqeyma® - Q5099​
  • Tofidence™ - Q5133​​
  • ​Tremfya® IV - J1628​
  • Tyenne® - Q5135​
  • Wezlana – Q5137, Q5138​
  • Yesintek™ - Q5100​

HCPCS codes J3362 and J3380 will only require precertification when not reported with the JB modifier.

Intravenous Immune Globulin/Su​​bcutaneous Immune Globulin (IVIG/SCIG)


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
 
  • Intravenous Immune Globulin (IVIG) ​
    • ​Alyglo™ - J1552
    • Asceniv® - J1554
    • Bivigam® - J1556
    • Flebogamma® - J1572
    • Flebogamma-Dif® - J1572
    • Gammagard Liquid® - J1569
    • Gammagard S/D® - J1566
    • Gammaked® - J1561
    • Gammaplex® - J1557
    • Gamunex-C® - J1561
    • Octagam® - J1568
    • Panzyga® - J1576
    • Privigen® - J1459 
  • Subcutaneous Immune Globulin (SCIG)
    • Cutaquig® - J1551
    • Cuvitru® - J1555
    • Hizentra® - J1559
    • Hyqvia® - J1575
    • ​​Xe​​​mbify® - J1558 


Multiple​ Scleros​is ​Agents


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

  • ​Briumvi™ - J2329
  • Lemtrada® - J0202
  • Ocrevus™ - J2350
  • Ocrevus Zunovo® - J2351​
  • Tyruko® - Q5134
  • ​Ty​sabri® - J2323 

Myasthenia Gravis Agents


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.​

  • Imaavy™ - C9305 and J3590​
  • Rystiggo® - J9333
  • Vyygart™ - J9332
  • Vyygart® Hytrulo - J9334

Neutropenia

​

  • Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Fylnetra® - Q5130​
  • ​Granix® - J1447​
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neupogen® - J1442
  • Nypozi® - Q5148​
  • Releuko™ - Q5125
  • Rolvedon™ - J1449​
  • Ryzneuta® - J9361​
  • Stimufend® - Q5127
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120


Ophthalmi​​​c Agents

​
  • Ahzantive® - Q5150​
  • Beovu® - J0179
  • Byooviz™ - Q5124
  • Cimerli™ - Q5128​
  • Encelto™ - J3403​
  • ​Enzeevu™ - Q5149​
  • ​Eylea® - J1078(Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​​
  • ​Eylea® HD - J1077 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Lucentis® - J2778 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • Opuviz - Q5153​
  • ​​Pavblu™ - Q5147​
  • Susvimo™- C2779
  • Tepezza® - J3241
  • Vabysmo® - J2777​
  • ​Yesafili™ - Q5155​

    • ​
    ​​​​​​

Pulmonary Arterial Hyperten​​​sion


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 
  • Flolan® - J1325
  • Remodulin® - J3285
  • Revatio® - J3490 and C9399
  • Tyvaso® - J7686
  • ​Uptravi® IV - J3490 and C9399​
  • Veletri® - J1325
  • Ventavis® - Q4074 


Respiratory Ag​​​ents 


  • Cinqair® - J2786
  • Omlyclo® - Q5154​
  • Synagis® - 90378
  • ​Xolair® - J2357 


Respiratory Enzyme​​s (Alpha-1 Antitrypsin)


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.  

  • Aralast - J0256
  • Glassia™ - J0257
  • Prolastin® - J0256
  • ​Zemaira® - J0256 

Tumor Infiltrating Lymphocyte (TIL) Therapy

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

 

  • Amtagvi™ – J3590, and C9399​
  • Imdelltra™- J9026​
  • ​Lynozyfic™ - C9399 and J3590​
  • Tecelra® - Q2057​


Miscellaneous Therapeuti​​​c Agents 


  • Adakveo® - J0791
  • Ampligen® (pending FDA approval) - J3490
  • Amvuttra™ - J0225​​
  • Bkemv™ - Q5152​
  • Cosela® - J1448​
  • Crysvita® - J0584
  • Enjaymo™ - J1302
  • Epysqli® - Q5151​
  • Evkeeza™ - J1305
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari® - J0223
  • Ilaris® - J0638
  • Injectafar® - J1439​
  • Krystexxa® - J2507
  • ​Lantidra® - J3490, J3590, and C9399​
  • Leqvio® - J1306​
  • Monoferric® - J1437​
  • Narsoplimab (pending FDA approval) - C9399 and J3590​
  • Niktimvo™ - J9038​
  • Onpattro® - J0222
  • Oxlumo™ – J0224
  • Panhemitin® - J1640​
  • ​PiaSky® - J1307​
  • Reblozyl® - J0896
  • Remune - J3490
  • Rethymic™ - J3590, and C9399
  • ​​Soliris® - J1299​
  • Spinraza™ - J2326
  • ​​Tzield™ - J9381​
  • Ultomiris™ - J1303
  • Uplizna™ – J1823
  • Veopoz™ - J9376​
  • Vyepti™ - J3032
  • Xiaflex® – J0775 

​Revisio​​​ns​
​

October 1, 2025

The following revisions were incorporated into the October 1, 2025 update.​​

Additions​​

Genetically and Bio-Engineered Skin Substitutes for Wound Care

A2036 Cohealyx collagen dermal matrix, per square centimeter
A2037 G4derm plus, per milliliter
A2038 Marigen pacto, per square centimeter
A2039 Innovamatrix fd, per square centimeter
Q4383 Axolotl graft ultra, per square centimeter
Q4384 Axolotl dualgraft ultra, per square centimeter
Q4385 Apollo ft, per square centimeter
Q4386 Acesso trifaca, per square centimeter
Q4387 Neothelium ft, per square centimeter
Q4388 Neothelium ft, per square centimeter
Q4389 Neothelium 4l+, per square centimeter
Q4390 Ascendion, per square centimeter
Q4392 Grafix duo, per square centimeter
Q4393 Surgraft ac, per square centimeter
Q4394 Surgraft aca, per square centimeter
Q4395 Acelagraft, per square centimeter
Q4396 Natalin, per square centimeter
Q4397 Summit aaa, per square centimeter

Custom Limb Prosthetics Including Accessories/Components

L5657 Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials

L6034 Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692

L6035 Single prosthetic digit, mechanical, can include metacarpophalangeal (mcp), proximal interphalangeal (pip), and/or distal interphalangeal (dip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

L6036 Prosthetic thumb, mechanical, can include metacarpophalangeal (mcp), interphalangeal (ip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

L6038 Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material

Radiology

Magnetoencephalography (MEG)

Head
95965, 95966

Antineoplastic Agents

Datroway® - J9011
Emrelist™ - C9306 and J3590

Bone-Modifying Agents

Bomyntra® and Conexxance® - Q5158
Ospomyv™ and Xbryk - Q5159
Stoboclo® and Osenvelt® - Q5157

Gene Replacement / Gene Editing Therapies

Zevaskyn™ - C9399 and J3590

Hemophilia/Coagulation Factors

Alhemo® - J7173
Qfitlia™ - J7174

Immunological Agents

Avtozma® - Q5156

Myasthenia Gravis Agents

Imaavy™ - C9305 and J3590

Ophthalmic Agents

Encelto™- J3403
Yesafili™ - Q5155

Respiratory Agents
 
Omlyclo® - Q5154

Tumor Infiltrating Lymphocyte (TIL) Therapy

Lynozyfic™ - C9399 and J3590​

______________________________________________________

Deletions

Antineoplastic Agents

Datroway® - C9174

Gene Replacement / Gene Editing Therapies
​
Prademagene zamikeracel - J3490, J3590, and C9399

Ophthalmic Agents

Yesafili™ - J3490, J3590, and C9399

Tumor Infiltrating Lymphocyte (TIL) Therapy

Linvoseltamab - J3490, J3590, and C9399​

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