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, click 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, click 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, click 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 PGTSM)

    • 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, click 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® - J9023
    • Imfinzi™ - J9173
    • Keytruda™ - J9271
    • Libtayo® - J9119
    • Opdivo® - J9299
    • Tecentriq™ - J9022


    Bone-modifying agents

    • Evenity™ - J3111
    • Prolia® - J0897
    • Xgeva® - J0897


    Botulinum toxin agents

    • Botox® - J0585


    Cardiovascular agents

    • Flolan® - J1325
    • Remodulin® - J3285
    • Veletri® - J1325


    Chemotherapy-induced nausea and vomiting (CINV) agents

    • Sustol® - J1627


    Chimeric 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, click 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






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    Issued on - 10/01/2019

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