The following sections of the Fidelis Care authorization grids have been updated effective October 1, 2024.
The following has been added to the Medicare, Medicaid, Essential Plan, and Ambetter By Fidelis Care Metal-Level Products Authorization Grids and requires prior authorization:
Behavioral Health - Outpatient services:
Transcranial Magnetic Stimulation (TMS) -
Covered; Authorization Required for CPT Codes 90867, 90868 and 90869
Requests for members can be made by email qhcmbh@fideliscare.org, fax (833-561-0098) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Behavioral Health, or dialing extension 16072.
Members over 18 years old may be eligible for this service when TMS is administered using an FDA-cleared device in accordance with the FDA labeled indications, and meeting additional criteria including a confirmed diagnosis of major depressive disorder (MDD) and failure to respond to a combination of multiple trials of medication and evidence-based psychotherapy treatment during the current episode of illness.
The following codes have been removed from the Medicaid DME Authorization Grid:
A4239 Supply allowance for non-adjunctive, non-implanted CGM
A6540 Gc stocking waistlngth 30-40
E0562 Humidifier, heated, used with positive airway pressure device
E0601 Cont Airway Pressure Device
E1390 Oxygen Concentrator
L0642 Lo sag ri an/pos pnl pre ots
The following codes have been added on the Medicaid, Essential Plan, and Ambetter By Fidelis Care Metal-Level Products Authorization Grids and require prior authorization:
C9169 nogapendekin alfa inbakicept-pmln (Anktiva)
C9170 tarlatamab-dlle (Imdelltra)
C9172 fidanacogene elaparvovec (Beqvez)
J0175 donanemab-azbt (Kisunla)
J8522 capecitabine 50 mg
J8541 dexamethasone (Hemady)
J9329 tislelizumab-jsgr inj (Tevimbra)
Q0519 Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription injectable drug, per 30-days
Q0520 Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved prescription injectable drug, per 60-days
Q5135 tocilizumab-aazg (Tyenne)
Q5136 denosumab-bbdz (Jubbonti, Wyost)
Evolent Oncology Program (New Century Health) will require review of the following codes for Medicaid, Medicare, Essential Plans and Metal-Level Products:
C9169 nogapendekin alfa inbakicept-pmln (Anktiva)
C9170 tarlatamab-dlle (Imdelltra)
J8522 capecitabine 50 mg
J9329 tislelizumab-jsgr inj (Tevimbra)
Q5136 denosumab-bbdz (Jubbonti, Wyost)
Visit: Authorization Grids