January 31, The services below are being added to the prior authorization list:

Transcription

1 January 31, 2019 Effective April 1, 2019, Blue Cross of Idaho is implementing changes to the Commercial and Medicare Advantage prior authorization list for medical and pharmacy services. Prior authorization changes may not apply to all contract types. Check member eligibility and prior authorization requirements before performing services. The services below are being added to the prior authorization list: Computer-assisted surgical navigational procedure for musculoskeletal procedures; image-less (List separately in addition to code for primary Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body Claviculectomy; partial Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic Coracoacromial ligament release, with or without acromioplasty Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Tenodesis of long tendon of biceps Resection or transplantation of long tendon of biceps Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation Capsulorrhaphy, anterior; with labral repair (eg, Bankart Capsulorrhaphy, anterior, any type; with bone block Capsulorrhaphy, anterior, any type; with coracoid process transfer Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block Capsulorrhaphy, glenohumeral joint, any type multi-directional instability Arthroplasty, glenohumeral joint; hemiarthroplasty Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

2 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft Revision of total hip arthroplasty; both components, with or without autograft or allograft Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft Revision of total hip arthroplasty; femoral component only, with or without allograft Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral Arthrotomy, with synovectomy, knee; anterior OR posterior Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area Arthrotomy with meniscus repair, knee Repair, primary, torn ligament and/or capsule, knee; collateral Repair, primary, torn ligament and/or capsule, knee; cruciate Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments Autologous chondrocyte implantation, knee Osteochondral allograft, knee, open Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) Ligamentous reconstruction (augmentation), knee; extra-articular Ligamentous reconstruction (augmentation), knee; intra-articular (open) Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extraatricular Arthroplasty, patella; with prosthesis Arthroplasty, knee; tibial plateau Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy

3 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Revision of total knee arthroplasty, with or without allograft; 1 component Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component Open osteochondral autograft; talus (includes obtaining graft[s]) Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate Arthroscopy, shoulder, surgical; capsulorrhaphy Arthroscopy, shoulder, surgical; repair of SLAP lesion Arthroscopy, shoulder, surgical; with removal of loose body or foreign body Arthroscopy, shoulder, surgical; synovectomy, partial Arthroscopy, shoulder, surgical; synovectomy, complete Arthroscopy, shoulder, surgical; debridement, limited Arthroscopy, shoulder, surgical; debridement, extensive Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary Arthroscopy, shoulder, surgical; with rotator cuff repair Arthroscopy, shoulder, surgical; biceps tenodesis Arthroscopy, hip, diagnostic with or without synovial biopsy (separate Arthroscopy, hip, surgical; with removal of loose body or foreign body Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum Arthroscopy, hip, surgical; with synovectomy Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

4 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate Arthroscopy, knee, surgical; with lateral release Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) Arthroscopy, hip, surgical; with labral repair

5 62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Percutaneous implantation of neurostimulator electrode array, epidural Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Revision or removal of implanted spinal neurostimulator pulse generator or receiver Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) cervical or thoracic; single level

6 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) cervical or thoracic; second level (List separately in addition to code for primary Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) lumbar or sacral; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) lumbar or sacral; second level (List separately in addition to code for primary Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary Chemodenervation of one extremity; 1-4 muscle(s) Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary Chemodenervation of one extremity; 5 or more muscles Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary

7 64647 Chemodenervation of trunk muscle(s); 6 or more muscles Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day 0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images (List separately in addition to code for primary 0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure with image guidance based on CT/MRI images (List separately in addition to code for primary 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level 0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level 0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary 0396T Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (List separately in addition to code for primary Destruction by neurolytic agent; other peripheral nerve or branch A9513 Lutetium (Lutathera) lu 177, dotatate, therapeutic, 1 millicurie

8 A9606 Radium ra-223 dichloride (Xofigo), per microcurie C9035 Injection, aripiprazole lauroxil (aristada initio), 1 mg C9036 Injection, patisiran, 0.1 mg (Onpattro) C9037 Injection, risperidone (perseris), 0.5 mg C9038 Injection, mogamulizumab-kpkc, 1 mg (Poteligeo) G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee J0517 Injection, benralizumab, 1 mg (Fasenra) J0567 Injection, cerliponase alfa, 1 mg J0584 Injection, burosumab-twza 1 mg (Crysvita) J0599 Injection, c-1 esterase inhibitor (human), (haegarda), 10 units J1301 Injection, edaravone, 1 mg (Radicava) J1628 Injection, guselkumab, 1 mg J1746 Injection, ibalizumab-uiyk, 10 mg (Trogarzo) J3245 Injection, tildrakizumab, 1 mg (Ilumya) J3316 Injection, triptorelin, extended-release, 3.75 mg (Triptodur) J3397 Injection, vestronidase alfa-vjbk, 1 mg (Mepsevii) J3398 Injection, voretigene neparvovec-rzyl, (Luxturna) 1 billion vector genomes J3591 Unclassified drug or biological used for esrd on dialysis J7170 Injection, emicizumab-kxwh, 0.5 mg (Hemlibra) J7203 Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu J7318 Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg J7329 Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg J7330 Autologous cultured chondrocytes, implant J9044 Injection, bortezomib, not otherwise specified, 0.1 mg J9057 Injection, copanlisib, 1 mg (Aliqopa) J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine (Vyxeos) J9173 Injection, durvalumab, 10 mg (Imfinzi) J9229 Injection, inotuzumab ozogamicin, 0.1 mg (Besponsa) J9311 Injection, rituximab 10 mg and hyaluronidase (Rituxan Hycela)

9 J9312 Injection, rituximab, 10 mg Q2042 Tisagenlecleucel, (Kymriah) up to 600 million car-positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose Q4183 Surgigraft, per square centimeter Q4184 Cellesta, per square centimeter Q4185 Cellesta flowable amnion (25 mg per cc); per 0.5 cc Q4186 Epifix, per square centimeter Q4187 Epicord, per square centimeter Q4188 Amnioarmor, per square centimeter Q4189 Artacent ac, 1 mg Q4190 Artacent ac, per square centimeter Q4191 Restorigin, per square centimeter Q4192 Restorigin, 1 cc Q4193 Coll-e-derm, per square centimeter Q4194 Novachor, per square centimeter Q4195 Puraply, per square centimeter Q4196 Puraply am, per square centimeter Q4197 Puraply xt, per square centimeter Q4198 Genesis amniotic membrane, per square centimeter Q4200 Skin te, per square centimeter Q4201 Matrion, per square centimeter Q4202 Keroxx (2.5g/cc), 1cc Q4203 Derma-gide, per square centimeter Q4204 Xwrap, per square centimeter Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg Q5109 Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg Q5111 Injection, pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components.