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​​​​​​​​​​​​​​​​​​​​​​​​​​Services that require precertification for Independence Medicare Advantage Members (Effective 10/01/2025)​


Services that require Precertification for Medicare Advantage Members


As of October 1, 2025, this list applies to all Independence Blue Cross HMO, POS, and PPO products.

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 Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable.  For additional information, refer to the current version of Medical Policy MA11.113, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound.

Arterial Ultrasound

93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931

Diagnostic Coronary Angiography

93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553, C7557, C7562

Percutaneous Coronary Intervention

92920, 92924, 9​​2928, 92933, 92937, 92943, C9600, C9602, C9604, C9607


​Procedures


  • Cochlear Implant Surgery and Associated Supplies/Bone-Anchored (Osseointegrated) Hearing Aids, Implantable Bone Conduction Hearing Aids

  • 69714, 69715, 69717, 69718, 69930, L6814, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693
     
  • Obesity Surgery

  • 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999
     

Musculoskeletal Procedures​

Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA00.047, Musculoskeletal Services.

Allograft

29032, 29033, 29034


Bone Grafts

20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938


Bone Growth Stimulator

E0748

Cervical Spine Surgery - Anterior Decompression with Fusion

22551, 22552, 22554, 22830, 22585, 63081, 63082


Cervical Spine Surgery - Anterior Decompression without Fusion

63075, 63076


Cervical Spine Surgery - Posterior Decompression with Fusion

22600, 22614, 22​632, 22634, 22830, 22864


Cervical Spine Surgery - Posterior Decompression without Fusion

63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63052, 63​​053


Cervical Total Disc Replacement (Arthroplasty)

0095T, 0098T, 22856, 22858, 22861, 22864


Hip Arthroscopy

27120, 27122, 29860, 29861, 29862, 29863, 29914, 29915, 29916


Hip Replacement

27125, 27130, 27132, 27134, 27137, 27138, S2118

Knee Arthroscopy

29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889


Knee Open

27331, 27332, 27333, 27334, 27335, 27345, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429


Knee Replacement

27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, J7330, S2112


Lumbar Decompression (Laminotomy/Laminectomy/Discectomy/Formanitomy)

63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, S2350, S2351


Lumbar Disc Replacement (Arthroplasty)

0164T, 0165T, 22857, 22860, 22862, 22865


Lumbar Fusion

22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22830

Sacroiliac Joint Fusion

27279, 27280, C1737​


Shoulder - Arthroscopic and Open Procedures

23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828


Shoulder Replacement

23470, 23472, 23473, 23474


Spinal Deformity (Scoliosis/Kyphosis)

22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22610, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308
Spinal Instrumentation

22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859


Vertebroplasty, Kyphoplasty

22510, 22511, 22​512, 22513, 22514, 22515, C7504, C7505, C7507, C7508


Interventional Pain Management Services

Precertification is performed by Carelon Medical Benefits Man​agement. Precertification review only applies to members for whom the Program is applicable. 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

  • Cervical or Thoracic Epidural Steroid Injection

62320, 62321, 64479, 64480

  • Lumbar or Sacral Epidural Steroid Injection

62322, 62323, 64483, 64484

Paravertebral Facet Injection/Nerve Block/Neurolysis

  • Cervical or Thoracic Facet Injection

64490, 64491, 64492

  • ​Cervical Radiofrequency Ablation

64633,​ 64634​

  • ​​Lumbar or Sacral Facet Injection

64493, 64494, 64495

  • ​​Lumbar Radiofrequency Ablation

64635, 64636

Sacroiliac Joint injections

27096, ​G0260


Spinal Cord and Nerve Root Stimulators

  • Implantation of Spinal Cord Stimulators

63650, 63655, 63663, 63664, 63685, 6​​3688


Regional Sympathetic Nerve Blocks

64510, 6​4520​


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, 15769, 15771, 15772, 15773, 15774, 15777, 19300, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4116, Q4130, Q4142, Q4143​, S2066, S2067, S2068
     
  • Breast Reduction
    15877, 19318
     
  • Breast Augmentation/Mammoplasty
    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
    17999
     
  • 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 Affirming Interventions 
    11920, 11921, 11922, 11960, 15877, 17380, 19303, 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
    A2001, A2002, A2004, A2007, A2008, A2009, A2010, ​A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, A2022, A2023, A2024, A2025, A2026,​ A2027, A2028, A2030, A2031, A2032, A2033, A2034, A2035, ​​A2036, A2037, A2038, A2039,​ Q4100, Q4101, Q4102, ​Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4126, Q4127, Q4128, 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, Q4199, Q4205, Q4206, Q4208, Q4209, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4228, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, ​​​Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q​4308, Q4309, ​Q4310, Q4311, Q4312, Q4314, ​Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4344, Q4345​, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4392, Q4393, Q4394, Q4395, Q4396, Q4396, Q4397​
    ​
  • Gynecomastia

    • 19300

  • 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, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202

Day Rehabilitation Programs

0931, 0932​​

Elective (Nonemergency) Ground, Air, and Sea Ambulance Transportation


A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961 

Outpatient Private-Duty Nursing

S9123, S9124

Outpatient Radiation Therapy

Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA09.020, Radiation Therapy Services.

Associated Services with Radiation Therapy

19296, 19297, 19298, 31643, 32553, 41019, 49411, 49412, 55875, 55876, 55920, 57155, 57156, 58346, 76873, 76965


Brachytherapy

0394T, 0395T, 77316, 77317, 77318, 7​7761, 77762, 77767, 77768, 77770, 77771, 77772, 77778, 77789, 77790, 77799, C9726, G0458


Cardiac Focal Ablation

0745T, 0746T,​ 0747T


Hyperthermia Treatment

77600, 77605, 77610, 77615, 77620


Image-Guided Radiation (IGRT)

77014, 77387, G6001, G6002, G6017


Intensity Modulated Radiation Therapy (IMRT)

77301, 77338, 77385, 77386, G6015, G6016


Intraoperative Radiation Therapy (IORT)

19294, 77424, 77425, 77469


Medical Radiation Physics, Dosimetry, and Treatment Devices

77295, 77300, 77306, 77307, 77321, 77331, 77332, 77333, 77334, 77336, 77370, 77399


Neutron Beam Radiation Therapy

77423


Neuro SRS

61796, 61797, 61798, 61799, 61800


Proton Beam Radiation Therapy

77520, 77522, 77523, 77525, S8030


Radiation Treatment Delivery

77401, 77402, 77407, 77412, 77417, A9609, G0562, G0563, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014


Radiation Treatment Planning

77261, 77262, 77263, 77280, 77285, 77290, 77293


Stereotactic Radiation Therapy

77371, 77372, 77373, 77432, 77435, G0339, G0340


Therapeutic Radiopharmaceuticals

77750, 79005, 79101, ​79403, A9513, A9543, A9590, A9606, A9607, A9699, C261​6, S2095​​


Radiology

Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA09.002, High-Technology Radiology Services.

Computed Tomography (CT)

  • Abdomen

74150, 74160, 7417​0

  • Abdomen and Pelvis

74176, 74177, 74178

  • Cervical Spine

72125, 72126, 72127

  • Chest

71250, 71260, 71270

  • Head

0042T, 70450, 70460, 70470

  • Lower Extremity

73700, 73701, 73702

  • Lumbar Spine

72131, 72132, 72133

  • Lung

712​71

  • Neck

70490, 70​​491, 70492

  • Orbit

70480, 70481, 70482

  • ​​Pelvis

72192, 72193, 72194

  • Sinus

70486, 70487, 70488

  • Thoracic Spine

72128, 72129, 72130

  • Upper Extremity

73700, 73701, 73702

Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET)/ ​Computed Tomography (CT)

  • Computed Tomography (CT) Heart for Calcium Scoring

75771

  • Coronary Computed Tomography (CT) and Computed Tomography Angiography (CTA)

0503T, 755​72, 75573, 75574, 75580

  • Tumor Imaging

78811, 7​8812, 78813​​, 78814, 78815, 78816

Computed Tomography Angiography (CTA)

  • ​​Abdome​n

74175

  • Abdomen and Pelvis

74174

  • Abdominal Arteries

75635

  • Chest

71275

  • Head

70496

  • Lower Extremity

73706

  • Lung

71271

  • Neck

70498

  • Pelvis

721​91

  • Upper Extremity

7320​​6


CT Heart for Calcium Scoring


75571

Diagnostic Computed Tomography (CT) Colonoscopy


74261, 74262

Fluorine-18 fluorodeoxyglucose (f-18 FDG)


S8085

Follow Up Study Computed Tomography (CT)


76380

Functional Magnetic Resonance Imaging (MRI) Brain


70554, 70555

Low-Field MRI


S8042

Magnetic Resonance Angiography (MRA)

  • Abdomen

74185, C8900, C8901, C8902

  • Chest

71555, C8909, C8910, C8911

  • Head

615, 70544, 70545, 70546

  • Lower Extremity

73725, C8912, ​C8913, C8914

  • Neck

615, 70547, 70548, 70549

​Pelvis

​​72​198, C8918, C8919, C8920

  • Spinal Canal

72159, C8931, C8932, C8933

  • Upper Extremity

73225, C8934, C8935, C8936


Magnetic Resonance Elastograhpy

76391

Magnetic Resonance Imaging (MRI)

  • Abdomen

74181, 74182, 74183, S8037

  • Bone Marrow

77084

  • Brain

70551, 70552, 7​0553

  • Breast

77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908

  • Cardiac

75557, 75559, 75561, 75563, 75565, C9762, C9763

  • Cervical Spine

72141, 72142, ​72156

  • Chest

71550, 71551, 71​552

  • Fetal

74712, 7​4713

  • Lower Extremity

73718, 73719, 73​720, 73721, 73722, 73723

  • ​Low Field MRI

S8042

  • Lumbar Spine

72148, 72149, 72158

  • Orbit

70540, 70542, 70543

  • Pelvis

72195, 72196, 72197

  • Temporomandibular Joint (TMJ)

70336

  • Thoracic Spine

72146, 72147, 72157

  • Upper Extremity (Any Joint)

73221, 73222, 73223

  • Upper Extremity (Non-Joint)

73218, 73219, 73220


Magnetic Resonance Spectroscopy (MRS)


76390

Magnetic Resonance Technology (MRT)


616

Nuclear Cardiology

  • Cardiac Blood Pool Imaging

78472, 78473, 78481, 78483, 78494, 78496

  • Infarct Imaging

0742T, 78451, 78452, 78453, 78454, 78466, 78468, 78469


Positron Emission Tomography (PET)

  • Brain Imaging

78608, 78609

  • Myocardial Imaging

78429, 78430, 78431 78432, 78433, 78434, 78459, 78491, 78492

  • Other Imaging Services

404


Quantitative Computed Tomography (QCT) Bone Densitometry


77078

Resting Transthoracic Echocardiography (TTE)


93303, 93304, 93306, 93307, 93308

  • Echocardiography Add-On Codes

​​           93319, 93320, 93321, 93325, 93353​​


​​Screening Computed Tomography (CT) Colonoscopy

74263

Stress Echocardiography


93350, 93351

Echocardiography Add-On Codes


93320, 93321, 93325, 93352

Transesophageal Echocardiography (TEE)


93312, 93313, 93314, 93315, 93316, 93317

  • Echocardiography Add-On Codes

93319, 93320, 93321, 93325


3-D Rendering

  • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Grouping

76376, ​​​76377


Prosthetics/Orthoses:


  • 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, L5615, 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, L57​83,​ L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, ​L5828, L5830, L5840, L5841,​ L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, ​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, L6028, L6029, L6030, L6031, L6032, L6033, L6037, 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, L6700, 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, L7406, ​L7499​, L5657, L6034, L6035, L6036, L6038​

Selected Durable Medical Equipment (DME)


  • ​​Bone G​rowth Stimulators

Low-Intensity Ultrasound​ Noninvasive Bone Growth Stimulation

E0760

Other Than Spinal Noninvasive Electrical Bone Growth Stimulation

E0747 

Spinal Noninvasive Electrical Bone Growth Stimulation

E0748

  • ​ Bone-Anchored (Osseointegrated) Hearing Aids

​​​69716, 69719, 69726, 69727,​ L8690, L8691, L8692, L8693, L86​94 


  • Continuous Positive Airway Pressure (CPAP) Devices, Bi-Level (Bi-PAP) Devices, and All Supplies

Precertification is performed by Carelon Medical Benefits Management. Precertificatio​n review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA07.058, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.


A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0561, E0562, E0601, E1399


  • 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, E2300,
E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, 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, K0830, K0831, 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

  • ​​​Insulin Pumps

E0784, E0787, 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 P​​recertification ​- See specific DME, orthoses, and prosthetics categories for Repair or Replacement codes that require precertification.

  • ​​​​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

In-Lab / Facility Sleep Studies

Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA07.058, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies. 

95782, 95783, 95805, 95807, 95808, 95810, 95811 ​

​All Transplant Procedures, with the Exception of Corneal Transplants


0584T, 0585T, 0586T, 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, 4413​3, 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


  • Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs)  
  • Repetitive transcranial magnetic stimulation (rTMS)

0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869


  • Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)


Autism Spectrum Disorders

  • Applied Behavioral Analysis

​​0362T, 0373T, 97151, 97152, 9​7153, 97154, 97155, 97156, 97157, 97158

​​

Genetic and Genomic Tests Requiring Precertification


Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy MA06.034, eviCore Lab Management Program.​

The following list is a guide to the types of genetic and genomic tests that require precertification. ​ 

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 Disease​s


  • 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


The following are the specific CPT and HCPCS codes for genetic and genomic tests that require pre-service reviews by CareCore National, LLC d/b/a eviCore healthcare (eviCore).


Molecular Pathology
0001U, 0005U, 0016U, 0017U, 0018U, 0019U, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0297U, 0298U, 0299U, 0300U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U, 0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0488U, 0489U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0501U, 0506U, 0507U, 0508U, 0509U, 0510U, 0516U, 0532U, 0533U, 0534U, 0536U, 0537U, 0538U, 0539U, 0540U, 0543U, 0544U, 0549U, 81162, 81163, 81164, 81165, 81166, 81167, 81173, 81174, 81185, 81186, 81189, 81190, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81493, 81518, 81522, 81523, 81542, 81552

Molecular HCPCS Codes
G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S3861, S3865, S3866, S3870

Multianalyte Assays with Algorithmic Analyses (MAAA)
0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0017M, 0020M, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0444U, 0523U, 0529U, 0530U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 81195, 81504, 81519, 81520, 81521, 81525, 81529, 81540, 81541, 81546, 81551, 81554, 81558, 81595

Unlisted Molecular Codes (When Reported With Genetic/Genomic Testing)
81479, 81599, 84999

Specialty Drugs Requiring Precertification


All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change.

Alzheimer's Disease Agents

  • Aduhelm® - J0172
  • Kisunla™ - J0175​
  • Leqembi® - J0174​

Amyotrophic Lateral Sclerosis Agents​​​

  • NurOwn® - J3490, J3590, and C9399​

Antineoplastic Agents

  • Abraxane® - J9264
  • Adstiladrin® - J9029​
  • Adcetris® - J9042
  • Anktiva® - J9028
  • Alymsys® - Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)​
  • Avastin® - C9257, J9035, and Q5129 (Note: Ophthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Avzivi® - J3490, J3590, and C9399​
  • Azedra®​* - A9590
  • Bizengri® - J9382​
  • Blincyto™ - J9039
  • Columvi™ - J9286​
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ – J9144
  • Datroway® - J9011
  • Elahere™ - J9063​
  • Elrexfio™ - J1323
  • Emrelist™ - C9306 and J3590
  • Enhertu® - J9358
  • Epkinly™ - J9321​
  • Erbitux® - J9055
  • Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Herceptin® Hylecta - J9356
  • Herzuma® - Q5113​
  • Imjudo® - J9347
  • Kadcyla® - J9354
  • Kimmtrak® - J9274​
  • Kyprolis® - J9047​
  • Lunsumio™ - J9350
  • ​Margenza™ - J9353​
  • ​Monjuvi® - J9349​
  • Ogivri™ - Q5114
  • Ontruzant® - Q5112
  • Opdualag™ - J9298​
  • Padcev-™ J9177
  • Patritumab deruxtecan - J3490, J3590, and C9399​
  • Pemfexy™ -J9304
  • Perjeta® - J9306
  • Phesgo™ – J9316
  • Pluvicto™* - J3490 and C9399
  • Polivy™- J9309
  • Poteligeo® - J9204
  • Provenge® - Q2043
  • Riabni™ - Q5123​
  • Rituxan® - J9312 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Rituxan Hycela™ - J9311
  • Rybrevant™ - J9061​​​​
  • Rylaze™ - J9021
  • Rytelo™ - J0870​
  • Sarclisa® - J9227
  • Taclantis (pending FDA approval) - J3490 and C9399
  • Talvey™ - J3055
  • Tecvayli™ - J9380 
  • Tivdak™ - J9273
  • Trodelvy® - J9317
  • Vyloy® - J1326
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ – J9223
  • Zevalin®* - A9543
  • Ziihera® - J9276
  • Zynlonta™ J9359


Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable.

​​

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
  • Camrelizumab (pending FDA approval) - J3490, J3590, and C9399
  • Imfinzi™ - J9173
  • Jemperli™ - J9272
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Loqtorzi™ - J3263​
  • Opdivo® - J9299
  • Opdivo Qvantig™ - J9289
  • Tecentriq™ - J9022
  • Tecentriq Hybreza™ - J9024​
  • Tevimbra® - J9329
  • ​Unloxcyt™ - J9275​
  • Zynyz™ - J9345​

Bone-Modifying Agents


  • Bomyntra® and Conexxance® - Q5158​
  • Evenity™ - J3111
  • Jubbonti® - Q5136​
  • Ospomyv™ and Xbryk - Q5159​
  • Prolia® - J0897
  • Stoboclo® and Osenvelt® - Q5157​
  • Wyost® - Q5136
  • Xgeva® - J0897


Botulinum Toxin Agents


  • Botox® - J0585

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.

  • Abecma® - Q2055
  • ​Aucatzyl® - Q2058
  • Breyanzi® - Q2054
  • Carvykti™ - Q2056​
  • Kymriah™ - Q2042
  • Tecartus™ - Q2053​
  • ​Yescarta™ - Q2041       
  • Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous – 38228

Endocrine/Metabolic A​gents


  • Lanreotide - J1932 
  • Lutathera®* - A9513 and A9699
  • Sandostatin® LAR - J2353
  • Somatuline® depot - J1930
  • Xenpozyme™ - J0218​

HCPCS J0801, Acthar® Gel, and HCPCS J0802, Ani, will only require precertification when not appended with modifier JB​

* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. Precertification review only applies to members for whom the Program is applicable. 
​ ​

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.
  • Aldurazyme® - J1931
  • Adzynma - J7171​
  • Brineura™ - J0567
  • Cerezyme® - J1786
  • Cinaxadamtase Alfa (pending FDA approval) – J3490, J3590, and C9399​
  • ​Cipaglucosidase Alfa (pending FDA approval) – J3490, J3590, and C9399​
  • Elaprase® - J1743
  • Elelyso® - J3060
  • Elfabrio® - J2508​
  • Fabrazyme® - J0180
  • Kanuma® - J2840
  • Lamzede® - J0217​
  • Lumizyme® - J0221
  • Mepsevii™ - J3397
  • Naglazyme® - J1458
  • Nexviazyme™ - J0219
  • Pombiliti™ - J1203​
  • Replagal® (pending FDA approval) - J3490
  • Revcovi™ - J3590 and C9399
  • Vimizim™ - J1322
  • ​Vpriv® - J3385​
  • Xenpozyme® - J3590 and C9399​

Gene Replacement / Gene Editing 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.

  • Casgevy™ - J3392
  • Eladocagene exuparvovec - J3490, J3590, and C9399​
  • Elevidys® - J1413
  • ​Hemgenix® - J1411​
  • Lenmeldy™ - J3391​
  • Luxturna™ - J3398
  • Lyfgenia™ - J3394​
  • Marnetegragene aututemcel - J3490, J3590, and C9399
  • ​Roctavian® - J1412​
  • Skysona® - J3590 and C9399
  • Vvjuvek™ - J3401​
  • Zevaskyn™ - C9399 and J3590​
  • Zolgensma® - J3399
  • Zynteglo® - J3393​

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
  • Alhemo® - J7173​
  • Alphanate® - J7186
  • Alphanine SD® - J7193
  • Alprolix® - J7201
  • Altuviiio™ - J7214​
  • Bebulin VH® - J7194
  • Benefix® - J7195
  • Coagadex® - J7175
  • Corifact® - J7180
  • Eloctate® - J7205
  • Esperoct®- J7204
  • Feiba NF® - J7198
  • Feiba VH®​ - J7198
  • Fibryga® - J7177
  • Fibryna® - J7178
  • Helixate FS® - J7192
  • Hemlibra® - J7170
  • Hemofil-M® - J7190
  • Humate-P® - J7187
  • Hympavzi™ - J7172​
  • Idelvion® - J7202
  • Ixinity® - J7213
  • Jivi® - J7199 and J7208
  • Koate-DVI® - J7190
  • Kogenate FS® - J7192
  • Kovaltry® - J7207 and J7211
  • Monoclate-P® - J7190
  • Mononine® - J7193
  • Novoeight® - J7182
  • Novoseven RT® - J7189
  • Novoseven® - J7189
  • Nuwiq® - J7209
  • Obizur®- J7188
  • Profilnine SD® - J7194
  • Qfitlia™ - J7174
  • Rebinyn® - J7203
  • Recombinate® - J7192
  • RiaSTAP® - J7178
  • Rixubis® - J7195 and J7200
  • Sevenfact® - J7212
  • 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
  • Supartz® - J7321
  • Synojoynt™ - J7331
  • Triluron™ - J7332
  • TriVisc™ - J7329
  • VISCO-3® - J7321

Immunological Agents


  • Actemra®- J3262
  • Avtozma® - Q5156​
  • Benlysta® IV- J0490
  • Entyvio™ - J3380
  • Ilumya™ - J3245
  • Imuldosa® - Q5098​
  • Omvoh™ - J2267​
  • Orencia® IV- J0129
  • Otulfi® - Q9999​
  • Pyzchiva® - Q9996 and Q9997
  • Saphnelo™ - J0491​
  • Selarsdi™ - Q9998
  • Simponi® Aria - J1602
  • Skyrizi® IV - J2327
  • Spevigo® - J1747
  • Stelara® - J3357 and J3358
  • Steqeyma® - Q5099​
  • Tofidence™ - Q5133​
  • Tremfya® IV - J1628​
  • Tyenne® - Q5135​
  • Wezlana – Q5137, Q5138​
  • ​Yesintek™ - Q5100​

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)​
    • Alyglo™ - J1552​
    • Asceniv® - J1554
    • Bivigam® - J1556
    • Flebogamma® - J1572
    • Flebogamma®-Dif - J1572
    • Gammagard® - J1569
    • Gammagard S/D® - J1566
    • Gammaked® - J1561
    • Gammaplex® - J1557
    • Gamunex-C® - J1561
    • Octagam® - J1568
    • Panzyga® - J1576
    • Privigen® - J1459 
  • Subcutaneous Immune Globulin (SCIG)
    • Cutaquig® - J1551
    • Cuvitru® - J1555
    • Hizentra® - J1559
    • Hyqvia® - J1575
    • Xembify®​ - J1558

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.
  • Briumvi™ - J2329
  • Lemtrada® - J0202
  • Ocrevus™ - J2350
  • Ocrevus Zunovo® - J2351​
  • Tyruko® - Q5134
  • Tysabri® - J2323

Myasthenia Gravis 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.

  • ​Imaavy™ - C9305 and J3590​
  • Rystiggo® - J9333
  • Vyvgart™ - J9332
  • Vyygart® Hytrulo - J9334​
​

Neutropenia


  • ​Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Fylnetra® - Q5130
  • Granix® - J1447​
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neupogen® - J1442
  • ​Nypozi® - Q5148
  • Releuko™ - Q5125​
  • Rolvedon™ - J1449
  • ​Ryzneuta® - J9361​
  • Stimufend® - Q5127​
  • Udenyca™ - Q5111
  • ​Ziextenzo® - Q5120


Ophthalmic Agents


  • ​Ahzantive® - Q5150​
  • Beovu® - J0179
  • Byooviz™ - Q5124
  • Cimerli™​ - Q5128​
  • Encelto™ - J3403​
  • Enzeevu™ - Q5149​
  • Eylea® - J1078(Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Eylea® HD – J1077 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Lucentis® - J2778 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • Opuviz - Q5153
  • Pavblu™ - Q5147​
  • Susvimo™- J2779
  • Tepezza® - J3241
  • Vabysmo® - J2777
  • Yesafili™ - Q5155

Pulmonary Arterial Hypertension


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.
  • Flolan® - J1325
  • Remodulin® - J3285
  • Revatio® - J3490 and C9399
  • Tyvaso® - J7686
  • ​​​Uptravi® IV - J3490 and C9399​
  • Veletri® - J1325
  • Ventavis® - Q4074

Respiratory Agents


  • Cinqair® - J2786
  • Omlyclo® - Q5154​
  • 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 t​hat are approved by the FDA in that class during the course of the benefit year.
  • Aralast - J0256
  • Glassia™ - J0257
  • Prolastin® - J0256
  • Zemaira® - J0256

Tumor Infiltrating Lymphocyte (TIL) 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.

  • ​Amtagv​i™ – J3590, and C9399​
  • Imdelltra™- J9026
  • Lynozyfic™ - C9399 and J3590​
  • Tecelra® - Q2057​

Miscellaneous Therapeutic Agents

  • Adakveo® - J0791
  • Ampligen® (pending FDA approval) - J3490
  • Amvuttra™ - J0225​
  • Bkemv™ - Q5152​
  • Cosela® - J1448
  • ​Crysvita® - J0584
  • Enjaymo™ - J1302​
  • Epysqli® - Q5151​
  • Evkeeza™ - ​J1305
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari® - J0223
  • Ilaris® - J0638
  • Injectafar® - J1439​
  • Krystexxa® - J2507
  • ​Lantidra® - J3490, J3590, and C9399​
  • Leqvio® - J1306​
  • Monoferric® - J1437​
  • Narsoplimab (pending FDA approval) - C9399 and J3590​
  • ​Niktimvo™ - J9038​
  • Onpattro® - J0222
  • Oxlumo™ - J0224
  • Panhemitin® - J1640​
  • ​PiaSky® - J1307​
  • Reblozyl® - J0896
  • Remune - J3490
  • Rethymic™ - J3590, and C9399
  • ​Soliris® - J1299​
  • Spinraza™ - J2326
  • ​Tzield™ - J9381
  • Ultomiris™ - J1303
  • Uplizna™ – J1823
  • Veopoz™ - J9376​
  • Vyepti™ - J3032​
  • Xiaflex® – J0775
​

Revisions


October 1, 2025

 
The following revisions were incorporated into the October 1, 2025 update.​

Additions

Genetically and Bio-Engineered Skin Substitutes for Wound Care

A2036 Cohealyx collagen dermal matrix, per square centimeter
A2037 G4derm plus, per milliliter
A2038 Marigen pacto, per square centimeter
A2039 Innovamatrix fd, per square centimeter
Q4383 Axolotl graft ultra, per square centimeter
Q4384 Axolotl dualgraft ultra, per square centimeter
Q4385 Apollo ft, per square centimeter
Q4386 Acesso trifaca, per square centimeter
Q4387 Neothelium ft, per square centimeter
Q4388 Neothelium ft, per square centimeter
Q4389 Neothelium 4l+, per square centimeter
Q4390 Ascendion, per square centimeter
Q4392 Grafix duo, per square centimeter
Q4393 Surgraft ac, per square centimeter
Q4394 Surgraft aca, per square centimeter
Q4395 Acelagraft, per square centimeter
Q4396 Natalin, per square centimeter
Q4397 Summit aaa, per square centimeter

Custom Limb Prosthetics Including Accessories/Components

L5657 Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials

L6034 Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692

L6035 Single prosthetic digit, mechanical, can include metacarpophalangeal (mcp), proximal interphalangeal (pip), and/or distal interphalangeal (dip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

L6036 Prosthetic thumb, mechanical, can include metacarpophalangeal (mcp), interphalangeal (ip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

L6038 Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material

Antineoplastic Agents

Datroway® - J9011
Emrelist™ - C9306 and J3590

Bone-Modifying Agents

Bomyntra® and Conexxance® - Q5158
Ospomyv™ and Xbryk - Q5159
Stoboclo® and Osenvelt® - Q5157

Gene Replacement / Gene Editing Therapies

Zevaskyn™ - C9399 and J3590

Hemophilia/Coagulation Factors

Alhemo® - J7173
Qfitlia™ - J7174

Immunological Agents

Avtozma® - Q5156

Myasthenia Gravis Agents

Imaavy™ - C9305 and J3590

Ophthalmic Agents

Encelto™- J3403
Yesafili™ - Q5155

Respiratory Agents

Omlyclo® - Q5154

Tumor Infiltrating Lymphocyte (TIL) Therapy

Lynozyfic™ - C9399 and J3590

Deletions​

Antineoplastic Agents

Datroway® - C9174

Gene Replacement / Gene Editing Therapies

Prademagene zamikeracel - J3490, J3590, and C9399

Ophthalmic Agents

Yesafili™ - J3490, J3590, and C9399

Tumor Infiltrating Lymphocyte (TIL) Therapy

Linvoseltamab - J3490, J3590, and C9399

CPT Copyright 2025 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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