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23-1449 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 (CMS).

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, changes and deletions, effective March 1, 2024

View the tables below for PA requirement changes for Health Net and CalViva Health Medi-Cal fee-for-service physicians and other providers.

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

Requirement

Comments

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

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

PA Deletions, effective March 1, 2024

Service type

Description

Echocardiogram

Currently managed by NIA:

  • Stress echocardiography
  • Transthoracic echocardiography (TTE)
  • Transesophageal echocardiography (TEE)

Additional information

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.



Last Updated: 12/18/2023