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News & AnnouncementsCoverage of the COVID-19 Vaccination for AmeriHealth Members (Retroactively effective to March 14, 2023. Issued April 12, 2023)4/12/2023
New PoliciesPrescription Digital Therapeutics and Mobile-Based Health Management Applications12.00.053/10/2023 11:00 AM4/10/20234/10/2023This is a New Policy.4/10/2023
New PoliciesMirvetuximab soravtansine-gynx (Elahere TM)08.02.014/24/20234/24/2023This is a New Policy.
Updated PoliciesAtezolizumab (Tecentriq®)08.01.69c3/3/2023 9:00 AM4/3/20234/3/2023Medical Necessity Criteria
Updated PoliciesInsertion of Implantable Infusion Pumps11.15.03m3/10/2023 9:00 AM4/10/20234/10/2023Medical Necessity Criteria
Updated PoliciesMusculoskeletal Services (AmeriHealth)00.01.66h4/9/20234/10/2023Medical Necessity Criteria;General Description, Guidelines, or Informational Update
Updated PoliciesBotulinum Toxin Agents08.00.26aa4/10/20234/10/2023Medical Necessity Criteria
Updated PoliciesCoverage of Anticancer Prescription Oral and Injectable Drugs and Biologics and Supportive Agents08.01.08l4/1/20234/10/2023Medical Coding
Updated PoliciesTreatment of Medical and Surgical Complications11.00.02g4/10/20234/10/2023Coverage and/or Reimbursement Position;Medical Coding
Updated PoliciesHigh-Technology Radiology Services (AmeriHealth)09.00.46an4/9/20234/10/2023General Description, Guidelines, or Informational Update
Updated PoliciesMaintenance Treatment of Opioid or Alcohol Use Disorder 08.01.37c4/10/20234/10/2023Medical Necessity Criteria
Updated PoliciesElectromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter07.03.21m4/10/20234/10/2023Medical Coding
Updated PoliciesPembrolizumab (Keytruda®)08.01.63d4/10/20234/10/2023Medical Necessity Criteria;Medical Coding
Updated PoliciesElective Abortion11.06.02k4/10/20234/10/2023Medical Necessity Criteria
Updated PoliciesServices Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers00.10.01ah4/1/20234/12/2023Coverage and/or Reimbursement Position
Updated PoliciesAnkle-Foot/Knee-Ankle-Foot Orthoses05.00.39s3/14/2023 9:00 AM4/13/20234/13/2023Coverage and/or Reimbursement Position;Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesManual Wheelchairs05.00.12j4/13/20234/13/2023Medical Coding;General Description, Guidelines, or Informational Update
Updated PoliciesSeat Lift Mechanisms05.00.43h4/13/20234/13/2023Medical Necessity Criteria
Updated PoliciesHospital Beds and Accessories05.00.56l4/17/20234/17/2023Coverage and/or Reimbursement Position;General Description, Guidelines, or Informational Update
Updated PoliciesPPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services00.01.25bj4/1/20234/17/2023Coverage and/or Reimbursement Position
Updated PoliciesExperimental/Investigational Services12.01.01bh4/1/20234/21/2023Medical Coding
Updated PoliciesPercutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)05.00.75a4/24/20234/24/2023Coverage and/or Reimbursement Position
Reissue PoliciesFetal Fibronectin Enzyme (fFN) Immunoassay06.02.04d12/4/20154/5/20234/5/2023
Reissue PoliciesAlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)06.02.29d7/1/20164/5/20234/5/2023
Reissue PoliciesPreimplantation Genetic Testing (AmeriHealth Administrators)06.02.24j10/1/20164/5/20234/5/2023
Reissue PoliciesTeprotumumab-trbw (Tepezza®)08.00.41a6/6/20224/5/20234/5/2023
Reissue PoliciesGenetic Testing for Congenital Long QT Syndrome (AmeriHealth Administrators)06.02.31g1/1/20214/5/20234/5/2023
Reissue PoliciesHuman Immunodeficiency Virus (HIV) Genotyping and Phenotyping (AmeriHealth Administrators)06.02.09g7/1/20164/5/20234/5/2023
Reissue PoliciesExtraction of Bony Impacted Teeth and Exposure of Impacted Teeth04.00.05d3/26/20144/5/20234/5/2023
Reissue PoliciesAlpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)08.00.91e1/4/20214/5/20234/5/2023
Reissue PoliciesSurgical Treatment of Femoroacetabular Impingement (Amerihealth Administrators)11.14.23d1/10/20214/5/20234/5/2023
Reissue PoliciesSpinal Cord Ganglion and Dorsal Root Ganglion Stimulation (Amerihealth Administrators)11.15.01x1/10/20214/5/20234/6/2023
Reissue PoliciesAutologous Chondrocyte Implantation (ACI) and Other Cell-based Treatments of Focal Articular Cartilage Lesions (Amerihealth Administrators)11.14.06j1/10/20214/5/20234/6/2023
Reissue PoliciesDenervation of the Spinal Nerves for Chronic Pain (Amerihealth Administrators)11.15.09p10/1/20214/5/20234/6/2023
Reissue PoliciesMeniscal Allograft Transplantation and Meniscal Implants (Amerihealth Administrators)11.14.03h1/10/20214/5/20234/6/2023
Reissue PoliciesOsteochondral Allograft Transplantation (Amerihealth Administrators)11.14.12f1/10/20214/5/20234/6/2023
Reissue PoliciesSpinal Discectomy (Amerihealth Administrators)11.14.29h7/1/20214/5/20234/6/2023
Reissue PoliciesOsteochondral Autograft Transplantation (Amerihealth Administrators)11.14.09h1/10/20214/5/20234/6/2023
Reissue PoliciesIntraoperative Neurophysiological Monitoring (INM)07.03.14q1/3/20224/5/20234/6/2023
Reissue PoliciesPreimplantation Genetic Testing (AmeriHealth Administrators)06.02.24j10/1/20164/5/20234/10/2023
Reissue PoliciesBelimumab (Benlysta®) for Intravenous Use08.00.99e10/24/20224/19/20234/20/2023
Reissue PoliciesOcrelizumab (Ocrevus®)08.01.38c9/17/20194/19/20234/20/2023
Reissue PoliciesAlemtuzumab (Lemtrada®)08.01.22d5/4/20204/19/20234/20/2023
Reissue PoliciesPertuzumab, Trastuzumab, and Hyaluronidase-zzxf (Phesgo®)08.01.72a3/21/20224/19/20234/20/2023
Reissue PoliciesSpinal Laminectomy (Amerihealth Administrators)11.14.28e1/1/20224/19/20234/20/2023
Reissue PoliciesSpinal Fusion (Amerihealth Administrators)11.14.27f1/1/20224/19/20234/20/2023
Reissue PoliciesFrenectomy, Frenotomy, or Frenoplasty for Ankyloglossia (Tongue-Tie)11.03.05e1/1/20214/19/20234/20/2023
Reissue PoliciesPercutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty (Amerihealth Administrators)11.14.10t1/1/20234/19/20234/20/2023
Reissue PoliciesArtificial Intervertebral Cervical Disc Insertion (Amerihealth Administrators)11.14.19p1/10/20214/19/20234/20/2023
Reissue PoliciesRisankizumab-rzaa (Skyrizi®) for Intravenous Use 08.01.95a1/1/20234/19/20234/20/2023
Reissue PoliciesEfgartigimod alfa - fcab (VyvgartTM)08.01.84b7/1/20224/19/20234/20/2023
Reissue PoliciesTebentafusp-tebn (Kimmtrak®)08.01.85b10/1/20224/19/20234/20/2023
Reissue PoliciesSurgical Correction of Strabismus11.05.07d9/7/20164/19/20234/20/2023
Reissue PoliciesTildrakizumab-asmn (Ilumya®)08.01.48b2/24/20204/19/20234/21/2023
Reissue PoliciesFull-Body Computerized Tomography (CT) Scan Screening09.00.24c3/25/20154/19/20234/21/2023
Coding UpdateeviCore Lab Management (AmeriHealth)06.02.52ab4/1/20234/3/2023
Coding UpdateImmune Prophylaxis for Respiratory Syncytial Virus (RSV)08.00.22p4/1/20234/5/2023
Coding UpdatePreventive Care Services00.06.02al4/1/20234/5/20234/5/2023
Coding UpdatePemetrexed (Alimta®), Pemetrexed (Pemfexy™)08.00.87k4/1/20234/6/2023
Coding UpdateCompression Garments05.00.37g4/1/20234/6/2023
Coding UpdateGender Affirming Interventions11.09.02m4/1/20234/10/2023
Coding UpdateTeclistamab-cqyv (Tecvayli™)08.01.98a4/1/20234/10/2023
Coding UpdateBevacizumab (Avastin®) and Related Biosimilars For Oncologic Use08.00.66t4/1/20234/10/2023
Coding UpdateLaboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products00.03.07aj4/1/20234/13/2023
Coding UpdateDurable Medical Equipment (DME) and Consumable Medical Supplies05.00.21ab4/1/20234/14/2023
Coding UpdateRepair and Replacement of Durable Medical Equipment (DME) and Prosthetic Devices05.00.44p4/1/20234/14/2023