Services that Require Precertification for Medicare Advantage Members
As of October 1, 2025, this list applies to all AmeriHealth New Jersey Medicare Advantage HMO, POS, EPO, and PPO 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 also go to amerihealthnj.com/html/providers/policies.html to learn more about precertification requirements for all products.
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 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 MA11.113, 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
Procedures
- 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
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 MA00.047, 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 Management 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
- Lumbar or Sacral Facet Injection
- Lumbar Radiofrequency Ablation
Sacroiliac Joint Injections
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 Potentially 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, A2036, A2037, A2038, A2039, 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, Q4208, 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, Q4308, 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, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4392, Q4393, Q4394, Q4395, Q4396, Q4396, Q4397
- Hair Transplant
15775, 15776
- Injectable Dermal Fillers
11950, 11951, 11952, 11954, Q2026, Q2028
- 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) Ground, Air, and Sea Ambulance Transportation
A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961
Outpatient Private-Duty Nursing
S9123, S9124
Day Rehabilitation Programs
0931, 0932
Outpatient Radiation Therapy
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 MA09.020, Radiation Therapy Services.
Associated Services with Radiation Therapy
19296, 19297, 19298, 31643, 32553, 41019, 49411, 49412, 55875, 55876, 55920, 57155, 57156, 58346, 76873, 76965
Brachytherapy
0394T, 0395T, 77316, 77317, 77318, 77761, 77762, 77767, 77768, 77770, 77771, 77772, 77778, 77789, 77790, 77799, C9726, G0458
Cardiac Focal Ablation
0745T, 0746T, 0747T
Hyperthermia Treatment
77600, 77605, 77610, 77615, 77620
Image-Guided Radiation (IGRT)
77014, 77387, G6001, G6002, G6017
Intensity Modulated Radiation Therapy (IMRT)
77301, 77338, 77385, 77386, G6015, G6016
Intraoperative Radiation Therapy (IORT)
19294, 77424, 77425, 77469
Medical Radiation Physics, Dosimetry, and Treatment Devices
77295, 77300, 77306, 77307, 77321, 77331, 77332, 77333, 77334, 77336, 77370, 77399
Neutron Beam Radiation Therapy
77423
Neuro SRS
61796, 61797, 61798, 61799, 61800
Proton Beam Radiation Therapy
77520, 77522, 77523, 77525, S8030
Radiation Treatment Delivery
77401, 77402, 77407, 77412, 77417, A9609, G0562, G0563, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014
Radiation Treatment Planning
77261, 77262, 77263, 77280, 77285, 77290, 77293
Stereotactic Radiation Therapy
77371, 77372, 77373, 77432, 77435, G0339, G0340
Therapeutic Radiopharmaceuticals
77750, 79005, 79101, 79403, A9513, A9543, A9590, A9606, A9607, A9699, C2616, S2095
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)
- 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
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
- Breast
77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908
- Cardiac
75557, 75559, 75561, 75563, 75565, C9762, C9763
- Cervical Spine
72141, 72142, 72156
- Lower Extremity
73718, 73719, 73720, 73721, 73722, 73723
- Lumbar Spine
72148, 72149, 72158
- 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
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
Prosthetics/Orthoses
Follow New Jersey orthotics and prosthetics mandate, as applicable. Items addressed by the mandate do not require precertification.
Selected Durable Medical Equipment (DME)
- 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 MA07.058, 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, E2300,
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, K0830, K0831, 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:
- 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 Generating Devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336
Medical 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 MA07.058, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.
95782, 95783, 95805, 95807, 95808, 95810, 95811
All Transplant Procedures, with the Exception of Corneal Transplants
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/Substance 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 Disorders
- 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 MA06.034, eviCore Lab Management Program.The following list is a guide to the types of genetic and genomic tests that require precertification.
Hereditary Cancer Syndromes
- 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 Diseases
- Long QT syndrome gene testing
- Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome)
Other Full Gene Analysis Testing
- Cystic fibrosis full gene sequencing and deletion/duplication analysis
- PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy)
Tests for Many Genetic Disorders Simultaneously
- 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 disorders panels
Specialty Oncology 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 Tests
- 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 methylation 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)
Genome-Wide Tests
- Microarray studies
- Whole exome testing
- Whole genome testing
- Mitochondrial genome or nuclear testing
ANY genetic test for more than one gene or condition (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 Precertification
All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change.
Alzheimer's Disease Agents
- Aduhelm® - J0172
- Kisunla™ - J0175
- Leqembi® - J0174
Amyotrophic Lateral Sclerosis Agents
- NurOwn® -
J3490, J3590, and C9399
Antineoplastic Agents
- 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
- Elahere™ - 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
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
- Opdivo® - J9299
- Opdivo Qvantig™ -
J9289
- Tecentriq™ - J9022
- Tecentriq Hybreza™ -
J9024
- Tevimbra® -
J9329
- Unloxcyt™ -
J9275
- Zynyz™ - J9345
Bone-Modifying Agents
- Bomyntra® and Conexxance® - Q5158
- Evenity™ - J3111
- Jubbonti® -
Q5136
- Ospomyv™ and Xbryk - Q5159
- Prolia® - J0897
- Stoboclo® and Osenvelt® - Q5157
- Wyost® -
Q5136
- Xgeva® - J0897
Botulinum Toxin Agents
Chimeric Antigen Receptor (CAR-T) 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.
- 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/Metabolic Agents
- Lanreotide - J1932
- Lutathera®* - A9513 and A9699
- Sandostatin® LAR - J2353
- Somatuline® depot - J1930
- Xenpozyme™ - J0218
HCPCS J0801, Acthar® Gel, and HCPCS J0802, Ani, will only require precertification when not appended with modifier JB
* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore).
Enzyme Replacement 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.
- 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 Factors
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
- Fibryna® - J7178
- 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
Immunological Agents
- Actemra®- J3262
- Avtozma® - Q5156
- Benlysta® IV- J0490
- Cosentyx® IV –
J3247
- Entyvio™ - J3380
- 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
- Tyenne® -
Q5135
- Tremfya® IV -
J1628
- Wezlana –
Q5137, Q5138
- Yesintek™ -
Q5100
Intravenous Immune Globulin/Subcutaneous 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® - 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
- Xembify® - J1558
Multiple Sclerosis 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
- Tysabri® - 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.
- Imaavy™ - C9305 and J3590
- Rystiggo® - J9333
- Vyvgart™ - 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
Ophthalmic 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™- J2779
- Tepezza® - J3241
- Vabysmo® - J2777
- Yesafili™ - Q5155
Pulmonary Arterial Hypertension
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 Agents
- Cinqair® - J2786
- Omlyclo® - Q5154
- Synagis® - 90378
- Xolair® - J2357
Respiratory Enzymes (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 Therapeutic 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
CPT Copyright 2025 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
AmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.
Revisions
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 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 |
