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Fidelis Care Authorization Grids Effective October 1, 2024
8/28/2024 • Posted by Provider Relations

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 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

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