Prior Authorization requirement changes effective November 1, 2023 (Healthy Blue + Medicare (HMO D-SNP))
Please note, this communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Effective November 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Blue Cross NC for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code(s):
| Code | Code Description |
| 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop |
| 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and |
| 0687T | Treatment of amblyopia using an online digital program; device supply, educational set-up, and initial session |
| 0688T | Treatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report |
| 0704T | Remote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment |
| 0705T | Remote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hour |
| 0706T | Remote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month |
| 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle |
| A2019 | Kerecis omega3 marigen shield, per square centimeter |
| A2020 | Ac5 advanced wound system (ac5) |
| A2021 | Neomatrix, per square centimeter |
| A4341 | Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each |
| A4342 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each |
| E1905 | Virtual reality cognitive behavioral therapy device (CBT), including pre-programmed therapy software |
| Q4265 | Neostim tl, per square centimeter |
| Q4266 | Neostim membrane, per square centimeter |
| Q4267 | Neostim dl, per square centimeter |
| Q4268 | Surgraft ft, per square centimeter |
| Q4269 | Surgraft xt, per square centimeter |
| Q4270 | Complete sl, per square centimeter |
| Q4271 | Complete ft, per square centimeter |
Not all PA requirements are listed here. Detailed PA requirements are available to providers at Experience Health Providers | Blue Cross NC and scroll down to Drug Information for Medicare Members and select Prior Approval and Quantity Limits or for contracted providers by accessing Availity.com.
Note: Availity, LLC is an independent company providing administrative services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina
NCBCBS-CR-028193-23-CPN27641 July 2023 UM AROW 4505