4/30/2024
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective June 1, 2024.
The following codes have been added on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:
J0209 sodium thiosulfate (Hope)
J1434 fosaprepitant (Focinvez)
The following codes have been added to the Medicaid DME Authorization Grid and require prior authorization:
E0468 Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions
E2298 Complex rehabilitative power wheelchair accessory, power seat elevation system, any type
K1037 Docking station for use with oral device/appliance used to reduce upper airway collapsibility
L5783 Addition to lower extremity, user adjustable, mechanical, residual limb volume management system
L5841 Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control
The following code has been removed from the Medicaid DME Authorization Grid and does not require prior authorization effective 4/1/24:
E2300 (Wheelchair accessory, power seat elevation system, any type)
Visit: Authorization Grids