Fidelis Care Authorization Grids Effective February 1, 2024
12/28/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective February 1, 2024.
The following code has been added to the Medicaid DME Authorization Grid and requires prior authorization:
L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system
The following codes have been removed from the Medicaid DME Authorization Grid and do not require prior authorization:
V2625 Enlargement of Eye Prosthesis
V2626 Reduction of Eye Prosthesis
The following code has been updated on the Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
J2781 pegcetacoplan inj (Syfovre)
The following code has been added to the Medicare Authorization Grid and requires prior authorization:
J0576 buprenorphine extended-release (Brixadi)
Visit: Authorization Grids