2/28/2024
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective April 1, 2024.
The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:
H. Therapeutic Services:
1. Pain Management Codes (i.e. injections, TENS, therapeutic services): 20526, 20550, 20551, 20552, 20553, 21073, 27096, 62263-62264, 62273, 62280, 62281, 62282, 62290, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 63622, 64400-64530, 64553-64595, 64600-64640, 64582, 64583, 64628, 64629
Note: 63622 does not require authorization for requests from orthopedic specialties.
a. Interventional Pain Management: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, C1778, C1787, C1883, C1897
The following codes have been added to the Medicaid DME Authorization Grid and require prior authorization:
A4238 Supply allowance for adjunctive, non-implanted CGM
A4239 Supply allowance for non-adjunctive, non-implanted CGM
E2201 Manual wheelchair accessory, nonstandard seat frame, width 20-24 in.
E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
The following code has been added on the Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
C9293 glucarpidase (Voraxaze)
Visit: Authorization Grids