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Services that require precertification for Independence Commercial Members (Effective 10/01/2019)
Services that require precertification
As of January 1, 2019, this list applies to all Independence Blue Cross HMO, PPO, and POS products, including Flex products. This list was revised effective October 1, 2019 to incorporate updated medical codes. For Federal Employee Program (FEP) precertification requirements, please see the separate
FEP precertification list
.
This applies to services performed on an elective, nonemergency basis
Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded.
You can find additional information regarding preapproval/precertification, member cost-sharing and prescription drug coverage on the Independence
Preapproval/Precertification Requirements, Member Cost-Sharing, and Prescription Drug Formulary Lists
page.
All home-care services (including infusion therapy in the home)
Inpatient services
Acute rehabilitation admissions
Elective surgical and nonsurgical inpatient admissions
Inpatient hospice admissions
Long term acute care (LTAC) facility admissions
Skilled nursing facility admissions
Cardiology procedures
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM
Clinical Appropriateness Guidelines for Cardiology and Arterial Ultrasound
, click
here
.
Arterial ultrasound
Diagnostic coronary angiography
Percutaneous coronary intervention
Any procedure, device, or service that may potentially be considered experimental or investigational including:
New emerging technology/procedures, as well as existing technology and procedures applied for new uses and treatments
Procedures
Bronchial thermoplasty
31660, 31661
Cochlear implant surgery and associated supplies/bone-anchored (osseointegrated) hearing aids, implantable bone conduction hearing aids
69714, 69715, 69717, 69718, 69930, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693
Obesity surgery
43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999
Uvulopalatopharyngoplasty (UPPP)
42145
Musculoskeletal Procedures
Precertification is performed by AIM Specialty Health®, an independent company. For additional information, refer to the current version of Medical Policy #
00.01.66: Musculoskeletal Services
.
Bone graft substitutes and bone morphogenetic proteins for spine surgery
Cervical decompression with or without fusion cervical disc arthroplasty
Hip arthroplasty
Hip arthroscopy and open procedures
Knee arthroplasty
Knee arthroscopy and open procedures
Lumbar disc arthroplasty
Lumbar discectomy, foraminotomy, and laminotomy
Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
Lumbar laminectomy
Meniscal allograft transplantation of the knee
Shoulder arthroplasty
Shoulder arthroscopy and open procedures
Treatment of osteochondral defects
Vertebroplasty/Kyphoplasty
Interventional pain management services
Precertification is performed by AIM Specialty Health®, an independent company. For additional information, refer to the current version of Medical Policy #
00.01.66: Musculoskeletal Services
.
Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks
Paravertebral Facet Injection/Nerve Block/Neurolysis
Regional Sympathetic Nerve Block
Sacroiliac joint injections
Implanted spinal cord stimulators
Reconstructive procedures and potentially cosmetic procedures
Blepharoplasty/ptosis repair
15820, 15821, 15822, 15823
,
67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
Bone graft, genioplasty and mentoplasty
21120, 21121, 21122, 21123
Breast Reconstruction
11920, 11921, 11922, 11970, 11971, 15271, 15272, 15777, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, 20926, Q4100, Q4107, Q4130, S2066, S2067, S2068
Breast Reduction
15877, 19318
Breast Augmentation/Mammoplasty
19324, 19325
Breast Mastopexy
19316
Insertion of Breast Implants
19340, 19342, 19396
Removal of Breast Implants
19328, 19330, 19370, 19371
Canthopexy/Canthoplasty
21280, 21282, 67950
Cervicoplasty
15819
Chemical peels
15788, 15789, 15792, 15793
Dermabrasion
15780, 15781, 15782, 15783
Excision of excessive skin and/or subcutaneous tissue
15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839
Gender reassignment surgery
11960, 19303, 19304, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
Genetically and bio-engineered skin substitutes for wound care
Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222
Hair transplant
15775, 15776
Injectable dermal fillers
11950, 11951, 11952, 11954, Q2026, Q2028
Keloid removal
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
Lipectomy, liposuction, or any other excess fat-removal procedure
15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879
Otoplasty
13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399
Rhinoplasty
30400, 30410, 30420, 30430, 30435, 30450
Rhytidectomy
15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876
Scar revision
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830
Skin closures
13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770
Surgery for varicose veins, including perforators and sclerotherapy
36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799
Elective (nonemergency) ground, air, and sea ambulance transportation
A0140, A0426, A0428, A0430,
A0431
,
A0434,
S9960, S9961
Outpatient private-duty nursing
S9123, S9124
Day rehabilitation programs
0931, 0932
Outpatient radiation therapy
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, clic
k
here
.
Radiology
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Diagnostic Imaging Utilization Management Clinical Guidelines, click
here
.
CT
CTA
Echocardiography services
Testing transthoracic echocardiography (TTE)
Stress echocardiography (SE)
Transesophageal echocardiography (TE)
MRA
MRI
Nuclear cardiology
PET scans
Prosthetics/orthoses including:
Custom ankle-foot orthoses
L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631
Custom knee-ankle-foot orthoses
L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128
Custom knee braces
L1834, L1840, L1844, L1846, L1860
Custom limb prosthetics including accessories/components
L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6050, L6055, L6100, L6110, L6120, L6130, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7499
Selected durable medical equipment (DME)
Bone growth stimulators
E0747, E0760
Bone growth stimulator, electrical, noninvasive, spinal
Precertification is performed by AIM Specialty Health®, an independent company. For additional information, refer to the current version of Medical Policy #
00.01.66: Musculoskeletal Services
.
Bone-anchored (osseointegrated) hearing aids
L8690, L8691, L8692, L8693, L8694
Continuous positive airway pressure (CPAP) devices, bi-level (Bi-PAP) devices, and all supplies
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click
here.
Dynamic adjustable and static progressive stretching devices (excludes CPMs)
E1800, E1802, E1805, E1810, E1812, E1825, E1830
Electric, power, and motorized wheelchairs including custom accessories
E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294 E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2373, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613 E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630 K0010, K0011, K0012, K0013, K0014, K0056, K0108
,
K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823 K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898
External defibrillator and associated accessories
E0617, K0606
High frequency chest wall oscillation generator system
E0483
Insulin pumps
E0784, S1034
Manual wheelchairs with the exception of those that are rented
E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110 E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222 E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270 E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608 E2609, E2613,
E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628 E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108
Negative pressure wound therapy
A6550, A9272, E2402, K0743, K0744, K0745, K0746
Neuromuscular stimulators
E0744, E0745, E0764, E0770
Power operated vehicles (POV)
E1230, K0800, K0801, K0802, K0812
Pressure reducing support surfaces including:
Air fluidized bed
E0194
Non powered advanced pressure reducing mattress
E0371, E0373
Powered air flotation bed (low air loss therapy)
E0193, E0372
Powered pressure reducing mattress
E0277
Push rim activated power assist devices
E0986
Repair or replacement of all DME items, as well as orthoses and prosthetics that require precertification
E2368, E2369, E2370, E2374, E2375, E2376
Speech generating devices
E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336
Medical foods
B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435
Hyperbaric oxygen therapy
0413, G0277
Proton beam therapy
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, clic
k
here
.
Sleep studies (facility based)
Precertification is performed by AIM Specialty Health®, an independent company. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click
here.
Sleep studies (home-based)
Precertification will be performed by AIM Specialty Health®
, an independent company
. To access the complete list of AIM Specialty Health Sleep Disorder Management Diagnostic & Treatment Guidelines, click
here.
All transplant procedures, with the exception of corneal transplants
15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150
Mental health/serious mental illness/substance abuse
Precertification review for these services is provided by Magellan Healthcare, Inc., an independent company.
Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
Repetitive transcranial magnetic stimulation (RTMS)
Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
Autism spectrum disorders
Applied behavioral analysis
Precertification review for this service is provided by Magellan Healthcare, Inc., an independent company.
Genetic and genomic tests requiring precertification
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, clic
k
here
..
The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. To determine if a test requires precertification, please see the complete procedure code list for details.
Please note
: precertification of genetic and genomic tests applies to commercial members only.
Hereditary cancer syndromes
BRCA gene testing (breast and ovarian cancer syndrome)
Lynch syndrome gene testing
Familial adenomatous polyposis gene testing
PTEN gene testing (Cowden syndrome)
General cancer type panels (such as colon, breast, or neuroendocrine cancers)
Hereditary heart diseases
Long QT syndrome gene testing
Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome)
Other full gene analysis testing
Cystic fibrosis full gene sequencing and deletion/duplication analysis
PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy)
Tests for many genetic disorders simultaneously
Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening)
Hearing loss panels
Intellectual disability panels
Noonan spectrum disorders panels
Specialty oncology tests
Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™)
Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others)
Tissue of origin testing (for cancer of unknown primary)
PCA3 testing for prostate cancer
Pharmacogenomic tests
Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19)
Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGT
SM
)
Warfarin response testing
MGMT methylation analysis for glioblastoma
Other specialty tests
Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6)
Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR)
Genome-wide tests
Microarray studies
Whole exome testing
Whole genome testing
Mitochondrial genome or nuclear testing
ANY genetic test for more than one gene or condition (often includes words like “panel” or “comprehensive” in the name)
ANY genetic test that will be billed with a non-specific procedure code
Billed with CPT® codes
81400-81408
Billed with an unlisted code:
81479, 81599, 84999
Specialty drugs requiring precertification
All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change.
Antineoplastic agents
Abraxane® -
J9264
Adcetris® -
J9042
Alimta® -
J9305
Avastin® -
C9257 and J9035
(Note: Opthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Azedra -
C9408
Azedra Dosimetric -
C9407
Beleodaq® -
J9032
Blincyto™ -
J9039
Cyramza® -
J9308
Darzalex™ -
J9145
Elzonris™ -
J9269
Erbitux® -
J9055
Erwinaze® -
J9019
Folotyn® -
J9307
Halaven® -
J9179
Herceptin® -
J3490
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Herceptin® Hylecta -
J9356
Herzuma -
Q5113
Imlygic™ -
J9325
Istodax® -
J9315
Jevtana® -
J9043
Kadcyla® -
J9354
Kanjinti™ -
Q5117
Kyprolis® -
J9047
Lumoxiti™ -
J9313
Mvasi™
-
Q5107
(Note: Opthalmologic use of Mvasi does not require precertification.)
Ogivri -
Q5114
Ontruzant -
Q5112
Pemfexy -
J3490
Perjeta® -
J9306
Poteligeo® -
J9204
Provenge® -
Q2043
Rituxan® -
J9312
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Rituxan Hycela™ -
J9311
sacituzumab govitecan
(pending FDA approval)
-
J3490
Trazimera™ -
Q5116
Truxima™ -
Q5115
Xofigo®
*
-
A9606
Yervoy™ -
J9228
Zevalin®
*
-
A9543
Zirabev™
- Q5118
*
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, clic
k
here
.
Anti PD-1/PD-L1 human monoclonal antibodies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Bavencio® -
J
9023
Imfinzi™ -
J9173
Keytruda™ -
J9271
Libtayo®
- J9119
Opdivo® -
J9299
Tecentriq™ -
J9022
Bone-modifying agents
Evenity™ -
J3111
Prolia® -
J0897
Xgeva® -
J0897
Bo
tulinum toxin agents
Botox® -
J0585
Cardiovascular agents
Flolan® -
J1325
Remodulin® -
J3285
Veletri® -
J1325
C
hemotherapy-induced nausea and vomiting (CINV) agents
Sustol® -
J1627
C
himeric antigen receptor (CAR-T) therapies
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Kymriah™ -
Q2042
Yescarta™ -
Q2041
Colony stimulating factors
Fulphila™ -
Q5108
Neulasta® -
J2505
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Neulasta Onpro™ -
J2505
Nivestym™ -
Q5110
Udenyca™ -
Q5111
Endocrine/metabolic agents
H.P. Acthar® -
J0800
Lutathera®
*
-
A9513 and A9699
Makena® -
J1726 and J1729
Sandostatin® LAR -
J2353
Somatuline® depot -
J1930
*
Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. To access the eviCore website, clic
k
here
.
Enzyme replacement agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Adagen® -
J2504
Aldurazyme® -
J1931
Brineura™ -
J0567
Cerezyme® -
J1786
Elaprase® -
J1743
Elelyso® -
J3060
Fabrazyme® -
J0180
Kanuma® -
J2840
Lumizyme® -
J0221
Mepsevii™
- J3397
Naglazyme® -
J1458
Replagal®
(pending FDA approval)
-
J3490
Revcovi™
- J3590 and C9399
Vimizim™ -
J1322
VPRIV® -
J3385
Gene Therapy
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Luxturna™
-
J3398
Zolgensma®
-
J3490, J3590 and C9399
Hemophilia/Coagulation factors
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Advate -
J7192
Adynovate -
J7207
Afstyla -
J7210
Alphanate -
J7186
Alphanine SD -
J7193
Alprolix -
J7201
Autoplex T -
J7198
Bebulin VH -
J7194
Bebulin -
J7194
Benefix -
J7195
Bioclate -
J7192
Coagadex -
J7175
Corifact -
J7180
Eloctate -
J7205
Feiba NF -
J7198
Feiba VH -
J7198
Fibryga -
J7177
Fibryna -
J7178
Helixate FS -
J7192
Hemlibra -
J7170
Hemofil-M -
J7190
Humate-P -
J7187
Hyate-C -
J7191
Idelvion -
J7202
Ixinity -
J7199
Jivi® -
J7199 and J7208
Koate-DV I-
J7190
Kogenate FS -
J7192
Kovaltry -
J7207 and J7211
Monarc -
J7190
Monoclate-P -
J7190
Mononine -
J7193
Novoeight -
J7182
Novoseven RT -
J7189
Novoseven -
J7189
Nuwiq -
J7209
Obizur -
J7188
Profilnine SD -
J7194
Proplex T -
J7194
Rebinyn -
J7203
Recombinate -
J7192
Refacto -
J7192
RiaSTAP -
J7178
Rixubis -
J7195 and J7200
Tretten -
J7181
Vonvendi -
J7179 and J7199
Wilate -
J7183
Xyntha -
J7185
Hyaluronate acid products
Cingal
(pending FDA approval)
-
J3490
Durolane®
- J7318
Euflexxa™ -
J7323
Gel-One® -
J7326
Gelsyn-3™ -
J7328
GenVisc 850® -
J7320
Hyalgan® -
J7321
Hymovis® -
J7322
Monovisc® -
J7327
Supartz® -
J7321
TriVisc™ -
J7329
VISCO-3® -
J3490
Immunological agents
Actemra® -
J3262
Benlysta® -
J0490
Entyvio™ -
J3380
Ilumya™
-
J3245
Inflectra™ -
Q5103
Ixifi™ -
Q5109
Orencia® -
J0129
Remicade® -
J1745
(
Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Renflexis™ -
Q5104
Simponi® Aria -
J1602
Stelara
®
- J3357 and J3358
Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Intravenous Immune Globulin (IVIG)
Asceniv -
J1599
Bivigam -
J1556
Carimune -
J1566
Flebogamma -
J1572
Flebogamma-Dif -
J1572
Gammagard -
J1569
Gammagard Liquid -
J1569
Gammagard S/D -
J1566
Gammaked -
J1561
Gammaplex -
J1557
Gamunex-C -
J1561
Octagam -
J1568
Panzyga -
J1599
Privigen -
J1459
Subcutaneous Immune Globulin (SCIG)
Cutaquig -
J3490
Cuvitru -
J1555
Hizentra -
J1559
Hyqvia -
J1575
Multiple sclerosis agents
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Lemtrada® -
J0202
Ocrevus™ -
J2350
Tysabri® -
J2323
Respiratory agents
Cinqair® -
J2786
Fasenra™ -
J0517
Nucala® -
J2182
Synagis® -
90378
Xolair® -
J2357
Respiratory enzymes (Alpha-1 antitrypsin)
All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
Aralast -
J0256
Glassia™ -
J0257
Prolastin® -
J0256
Zemaira® -
J0256
Miscellaneous therapeutic agents
Ampligen®
(pending FDA approval)
-
J3490
Crysvita
-
J0584
Exenatide sustained-release ITCA 650
(pending FDA approval)
-
J3490
Exondys-51™ -
J1428
Ilaris
-
J0638
Gamifant® -
J9210
Krystexxa
-
J2507
Onpattro® -
J0222
Radicava
- J1301
ravulizumab
- J3490
Remune
(pending FDA approval)
-
J3490
Soliris® -
J1300
(Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
Soliris biosimilar
(pending FDA approval)
- J3590 and C9399
Spinraza -
J2326
Sylvant™ -
J2860
Trogarzo
-
J1746
Ultomiris™ -
J1303
Revisions
October 1, 2019
The following revisions were incorporated into the October 1, 2019 update.
Additions
: codes added
Reconstructive procedures and potentially cosmetic procedures
Genetically and bio-engineered skin substitutes for wound care
-
Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222
Antineoplastic agents
Elzonris™ -
J9269
Kanjinti™ -
Q5117
Lumoxiti™ -
J9313
Poteligeo® -
J9204
Trazimera™ -
Q5116
Zirabev™
- Q5118
Anti PD-1/PD-L1 human monoclonal antibodies
Libtayo®
- J9119
Bone-modifying agents
Evenity™ -
J3111
Miscellaneous therapeutic agents
Gamifant® -
J9210
Onpattro® -
J0222
Ultomiris™
- J1303
Deletions
: codes removed
Antineoplastic agents
Elzonris™ -
J3590 and C9049
Lumoxiti™ -
J3590 and C9045
Poteligeo® -
J3590 and C9038
Anti PD-1/PD-L1 human monoclonal antibodies
Libtayo®
- J9999 and C9044
Bone-modifying agents
Evenity™ -
J3590 and C9399
Miscellaneous therapeutic agents
Gamifant® -
J3590 and C9050
Onpattro® -
J3590 and C9036
Ultomiris™
- J3590 and
C9052
_________________________________________
July 1, 2019
The following revisions were incorporated into the July 1, 2019 update.
Additions
: codes added
Bone-modifying agents
Evenity™ -
J3590 and C9399
Antineoplastic agents
Elzonris™ -
C9049
Herceptin® Hylecta -
J9356
Herzuma -
Q5113
Ogivri -
Q5114
Ontruzant -
Q5112
Truxima™ -
Q5115
Gene Therapy
Zolgensma®
-
J3590 and C9399
Hemophilia/Coagulation factors
Jivi® -
J7208
Intravenous Immune Globulin/Subcutaneous Immune Globulin (IVIG/SCIG)
Intravenous Immune Globulin (IVIG)
Asceniv -
J1599
Miscellaneous therapeutic agents
Gamifant® -
C9050
Ultomiris™
-
C9052
Deletions
: codes removed
Antineoplastic agents
Elzonris™ -
C9399
Herzuma -
J3490
Ogivri -
J3490
Ontruzant -
J3490
Truxima™ -
J3590 and C9399
Hemophilia/Coagulation factors
Jivi® -
C9141
Miscellaneous therapeutic agents
Gamifant® -
C9399
Ultomiris™
-
C9399
_________________________________________
April 1, 2019
The following revisions were incorporated into the April 1, 2019 update.
Additions
: codes added
Elective (nonemergency) ground, air, and sea ambulance transportation
A0431, S9960, S9961
Anti PD-1/PD-L1 human monoclonal antibodies
Libtayo®
- C9044
Antineoplastic agents
Lumoxiti™ -
C9045
Colony stimulating factors
Udenyca™ -
Q5111
Hemophilia/Coagulation factors
Jivi® -
C9141
Deletions
: codes removed
Reconstructive procedures and potentially cosmetic procedures
Surgery for varicose veins, including perforators and sclerotherapy -
36473, 36474
CPT Copyright 2018 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.
Issued on - 10/01/2019
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