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Fidelis Care Authorization Grids Effective November 1, 2024
2024/9/25 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated effective November 1, 2024.

 

The following codes have been added to the Medicaid DME Authorization Grid:

 

A4543

Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month

A4544

Electrode for external lower extremity nerve stimulator for restless legs syndrome

A4545

Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month

C8000

Support device, extravascular, for arteriovenous fistula (implantable)

E0469

Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device

E0683

Non-pneumatic, non-sequential, peristaltic wave compression pump

E0715

Intravaginal device intended to strengthen pelvic floor muscles during kegel exercises

E0716

Supplies and accessories for intravaginal device intended to strengthen pelvic floor muscles during kegel exercises

E0721

Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region

E0737

Transcutaneous tibial nerve stimulator, controlled by phone application

E0743

External lower extremity nerve stimulator for restless legs syndrome, each

E0767

Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency electromagnetic field device, for cancer treatment, includes all accessories

E2513

Accessory for speech generating device, electromyographic sensor

E3200

Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only

L1006

Scoliosis orthosis, sagittal-coronal control provided by a rigid lateral frame, extends from axilla to trochanter, includes all accessory pads, straps and interface, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1653

Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf

L1821

Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf

L8720

External lower extremity sensory prosthesis, cutaneous stimulation of mechanoreceptors proximal to the ankle, per leg

L8721

Receptor sole for use with L8720, replacement, each

 

 

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