Commercial
Advanced Search

​​​​​​​​​​​​​​​​​​​​​​​Services that require precertification for AmeriHealth Pennsylvania Members (Effective 04/01/2025)

Services that require precertification 


As of April 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, an independent company.
  • Arterial ultrasound 
  • Diagnostic coronary angiography 
  • Percutaneous coronary intervention 

Proce​​​dures
  • Cochlear implant surgery and associated supplies/bone-anchored (osseointegrated) hearing aids, implantable bone conduction hearing aids

    69714, 69715, 69717, 69718, 69930, 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, an independent company.  For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.  

  • Bone graft substitutes and bone morphogenetic proteins for spine surgery 
  • Cervical decompression with or without fusion 
  • Cervical disc arthroplasty 
  • Hip arthroplasty 
  • Hip arthroscopy and open procedures 
  • Knee arthroplasty
  • Knee arthroscopy and open procedures 
  • Lumbar disc arthroplasty 
  • Lumbar discectomy, foraminotomy, and laminotomy 
  • Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis) 
  • Lumbar laminectomy 
  • Meniscal allograft transplantation of the knee 
  • Shoulder arthroplasty 
  • Shoulder arthroscopy and open procedures 
  • Treatment of osteochondral defects 
  • ​Vertebroplasty/Kyphoplasty 


Interventional pain manageme​​nt services


Precertification is performed by Carelon Medical Benefits Management, an independent company.  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
  • Paravertebral Facet Injection/Nerve Block/Neurolysis 
  • Regional Sympathetic Nerve Block 
  • Sacroiliac joint injections 
  • ​Implanted spinal cord stimulators 


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, Q4345, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367
    ​


     
  • Hair transplant

    15775, 15776
     
  • 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
 

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 review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). 

​

Radiology


Precertification is performed by Carelon Medical Benefits Management, an independent company.
  • CT 
  • CTA 
  • Echocardiography services
    • Testing transthoracic echocardiography (TTE) 
    • Stress echocardiography (SE) 
    • Transesophageal echocardiography (TE)
  • MRA 
  • MRI 
  • Nuclear cardiology 
  • ​PET scans 

Prosthetics/orthoses​​​ including: 


  • 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, L​​5060, 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
 

Selected durable medi​​​​cal equipment (DME) 


  • Bone growth stimulators

    E0747, E0760
     
  • Bone growth stimulator, electrical, noninvasive, spinal

    Precertification is performed by Carelon Medical Benefits Management, an independent company.  For additional information, refer to the current version of Medical Policy #00.01.66: Musculoskeletal Services.
     
  • 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, an independent company.
     
  • 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, an independent company.


Proton beam ther​​apy


Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).

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


Autism spectrum diso​​​rders 


  • Applied behavioral analysis

Genetic and genomic tests requiring ​​​precertification


Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).​

The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. To determine if a test requires precertification, please see the complete procedure code list for details. Please note: precertification of genetic and genomic tests applies to commercial members only. 


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


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
  • Blincyto™ - J9039
  • Columvi™ - J9286​
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ – J9144
  • Elahe​re™ - J9063
  • ​Elrexfio™ - J1323​
  • 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
  • Loqtorzi™ - J3263​
  • 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® - J3590 and C9303​
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ ​ – J9223
  • Zevalin®* - A9543
  • Ziihera® - J3590 and C9302​
  • Zolbetuximab (pending FDA approval) - J3490, J3590, and C9399​
  • Zynlonta™ J9359
    •  
    * Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).


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
  • Cosentyx® IV – J3247​
  • Cosibelimab (pending FDA approval) - J3490, J3590, and C9399
  • Imfinzi™ - J9173
  • Jemperli™ - J9272
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Opdivo® - J9299
  • Opdivo Qvantig™ - J3590 and C9399
  • Penpulimab (pending FDA approval) - J3490, J3590, and C9399
  • Tecentriq™ - J9022​
  • Tecentriq Hybreza™ - J9024​
  • Tevimbra® - J9329​
  • Zynyz™ - J9345​
    • ​

Bone-modifying a​​gents 


  • Evenity™ - J3111
  • Jubbonti® - Q5136
  • Prolia® - J0897
  • 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® - C9301​
  • ​Breyanzi® - Q2054
  • Carvykti™ - Q2056
  • Kymriah™ - Q2042
  • Obecabtagene autotemcel - J3490, J3590, and C9399
  • 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).​


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.
​
  • Beqvez™ - J1414​​
  • Casgevy™ - J3392
  • ​Eladocagene exuparvovec - J3490, J3590, and C9399​
  • Elevidys® - J1413
  • Hemgenix® - J1411​
  • Lenmeldy™ - J3590 and C9399​
  • Luxturna™ - J3398​
  • Lyfgenia™ - J3394
  • ​Marnetegragene aututemcel - J3490, J3590, and C9399
  • Prademagene zamikeracel - J3490, J3590, and C9399​
  • Roctavian® - J1412​
  • Skysona® - J3590 and C9399​
  • Vvjuvek™ - J3401​
  • 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
  • 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™ - J3590 and C9304​
  • 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
  • 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.)
  • Benlysta® IV - J0490
  • Entyvio™ - J3380 (See note below.)
  • Ilumya™ - J3245​​​
  • 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  
  • Tofidence™ - Q5133​​
  • ​Tremfya® IV - J1628​
  • Tyenne® - Q5135​
  • Wezlana – Q5137, Q5138​


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 

Myasthemia 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.​

  • 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 and C9173​
  • Releuko™ - Q5125
  • Rolvedon™ - J1449​
  • Ryzneuta® - J9361​
  • Stimufend® - Q5127
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120


Ophthalmi​​​c agents

​
  • Ahzantive® - Q5150​
  • Beovu® - J0179
  • Byooviz™ - Q5124
  • Cimerli™ - Q5128​
  • ​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 - J3490, J3590, and C9399
  • ​​Pavblu™ - Q5147​
  • Susvimo™- C2779
  • Tepezza® - J3241
  • Vabysmo® - J2777​
  • ​Yesafili™ - J3490, J3590, and C9399​

    • ​
    ​​​

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
  • Veletri® - J1325
  • Ventavis® - Q4074 


Respiratory ag​​​ents 


  • Cinqair® - J2786
  • 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
  • Linvoseltamab - J3490, J3590, and C9399
  • 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 (pending FDA approval) - J3490
  • Rethymic™ - J3590, and C9399
  • ​​Soliris® - J1299​
  • Spinraza™ - J2326
  • ​​Tzield™ - J9381​
  • Ultomiris™ - J1303
  • Uplizna™ – J1823
  • Veopoz™ - J9376​
  • Vyepti™ - J3032
  • Xiaflex® – J0775 

​Revisio​​​ns​
​

April 1, 2025

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

Additions​​

Custom limb prosthetics including accessories/components

L5827 Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping

L6028 Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, not including inserts described by l6692

L6029 Upper extremity addition, test socket/interface, partial hand including fingers

L6030 Upper extremity addition, external frame, partial hand including fingers

L6031 Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power

L6032 Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal)

L6033 Addition to upper extremity prosthesis, partial hand including fingers, acrylic material

L6037 Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers

L6700 Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement

L4706 Addition to upper extremity, user adjustable, mechanical, residual limb volume management system

Genetically and bio-engineered skin substitutes for wound care

A2030 Miro3d fibers, per milligram

A2031 Mirodry wound matrix, per square centimeter

A2032 Myriad matrix, per square centimeter

A2033 Myriad morcells, 4 milligrams

A2034 Foundation drs solo, per square centimeter

A2035 Corplex p or theracor p or allacor p, per milligram

Q4354 Palingen dual-layer membrane, per square centimeter

Q4355 Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter

Q4356 Abiomend membrane and abiomend hydromembrane, per square centimeter

Q4357 Xwrap plus, per square centimeter

Q4358 Xwrap dual, per square centimeter

Q4359 Choriply, per square centimeter

Q4361 Epixpress, per square centimeter

Q4362 Cygnus disk, per square centimeter

Q4363 Amnio burgeon membrane and hydromembrane, per square centimeter

Q4364 Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter

Q4365 Amnio burgeon dual-layer membrane, per square centimeter

Q4366 Dual layer amnio burgeon x-membrane, per square centimeter

Q4367 Amniocore sl, per square centimeter
 
Surgery for varicose veins, including perforators and sclerotherapy

36468 Injection(s) of Sclerosant for Spider Veins (Telangiectasia), Limb or Trunk

36482 Endovenous Ablation Therapy of Imcompetent Vein, Extremity, by Transcatheter Delivery of a Chemical adhesive (e.g. Cryanoacrylate) Remote from the Access Site, Inclusive of All Imaging Guidance and Monitoring, Percutaneous; First Vein Treated
 
36483 Endovenous Ablation Therapy of Imcompetent Vein, Extremity, by Transcatheter Delivery of a Chemical adhesive (e.g. Cryanoacrylate) Remote from the Access Site, Inclusive of All Imaging Guidance and Monitoring, Percutaneous; Subsequent Vein(s) Treated in a Single Extremity, Each Through Separate Access Sites (List Separately in Addition to Core for Primary Procedure

S2202 Echosclerotherapy

Antineoplastic agents

Vyloy® - J3590 and C9303
Ziihera® - J3590 and C9302

Anti PD-1/PD-L1 human monoclonal antibodies

Tecentriq Hybreza™ - J9024

Chimeric antigen receptor (CAR-T) therapies​

Aucatzyl® - C9301

Hemophilia/Coagulation factors

Hympavzi™ - J3590 and C9304

Immunological agents

Otulfi® - Q9999

Multiple sclerosis agents

Ocrevus Zunovo® - J2351

Neutropenia

Nypozi® - Q5148 and C9173

Ophthalmic agents

Ahzantive® - Q5150
Enzeevu™ - Q5149
Pavblu™ - Q5147

Tumor Infiltrating Lymphocyte (TIL) Therapy

Tecelra® - Q2057

Miscellaneous therapeutic agents

Bkemv™ - Q5152
Epysqli® - Q5151
Niktimvo® - J9038
Panhemitin® - J1640
Soliris® - J1299

___________________________________________________________

Deletions

Genetically and bio-engineered skin substitutes for wound care

Q4231 Corplex p, per cc
 
Obesity Surgery

43842 Vertical Banded Gastroplasty

Anti PD-1/PD-L1 human monoclonal antibodies

Tecentriq Hybreza™ - J3590, J9999, and C9399

Hemophilia/Coagulation factors

Hympavzi™ - J3590 and C9399

Neutropenia

Nypozi® - J3590 and C9173

Ophthalmic agents

Ahzantive® - J3490, J3590, and C9399
Enzeevu™ - J3490, J3590, and C9399
Pavblu™ - J3490, J3590, and C9399

Tumor Infiltrating Lymphocyte (TIL) Therapy
 
Tecelra® - J3490, J3590, and C9399
 
Miscellaneous therapeutic agents

Bkemv™ - Q5139
Epysqli® - J3490, J3590, and C9399
Niktimvo® - J3490, J3590, and C9399

Soliris® - J1300 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​


CPT Copyright 2025​ American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.  

AmeriHealth HMO, Inc.