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23-1448 Prior Authorization Changes Effective March 1, 2024

Date: 12/20/23

Get prior authorization for medical benefit drugs and services listed in this update

The below medical benefit medications require prior authorization (PA) per new HCPCS codes issued by the Centers for Medicare & Medicaid Services. This applies to the Los Angeles County Department of Health Services (LA-DHS).

Medications Newly approved by the FDA require PA effective immediately

The following medication newly approved by the U.S. Food and Drug Administration (FDA) requires prior authorization.  

Requirement

Comments

ElevidysTM

Infusion, gene therapy, single dose

PA additions and changes, effective March 1, 2024

View the tables below for PA requirement changes.

OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT):

PA Additions, effective March 1, 2024

Requirement

Comments

Arzerra®

  • J9302, injection, ofatumumab, 10 mg

Novantrone®

  • J9293, injection, mitoxantrone hydrochloride, per 5 mg

Signifor® LAR

  • J2502, injection, pasireotide long acting, 1 mg

Valstar®

  • J9357, injection, valrubicin, intravesical, 200 mg

PA Change, effective March 1, 2024

Vegzelma®

  • Q5129, injection, bevacizumab-adcd, biosimilar, 10 mg
  • No longer requires PA for ophthalmologists

OUTPATIENT SERVICES

PA Additions, effective March 1, 2024 – Leg stent bridge

The following codes are authorized by Health Net when provided outside of an LA-DHS facility.

Procedure Code

Description

37220

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

37221

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37224

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

37225

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed

37226

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37227

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37228

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

37229

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed

37230

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37231

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800-675-6110.

 

This information applies to Hospitals/Clinics.

For Medi-Cal, this information applies to Los Angeles (LA-DHS).



Last Updated: 12/18/2023