Effective 4/1/2026
 

Beginning April 1, the prior authorization status has changed for some HCPCS codes and services. 

 

Changes to prior authorization and medical necessity review for these services are part of AmeriHealth Caritas Ohio’s continued dedication to supporting providers in our shared commitment to high quality healthcare for our members.

 

As a reminder, when you do need to verify whether a service requires prior authorization, use the Prior Authorization Lookup Tool on the provider website at: https://www.amerihealthcaritasoh.com/provider/resources/prior-auth-lookup-tool.

 

Questions? Please contact your Provider Account Executive or Provider Services at

1-833-644-6001.

Procedure
Code

Procedure Code Description

Prior
Authorization
Rule

0614U

Inborn error of metabolism (primary mitochondrial disease), mitochondrial analysis of 4 enzyme complexes by stained blue native polyacrylamide gel electrophoresis (PAGE), frozen tissue (muscle, liver, heart, cultured skin fibroblasts), diagnostic qualitat

Yes

0615U

Borrelia burgdorferi (Lyme disease), antibody detection of 26 recombinant protein groups, by immunoassay, IgM

Yes

0616U

Neurology (dementia), DNA methylation analysis of more than 30,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0617U

Cardiovascular (atherosclerotic cardiovascular disease [ASCVD]), DNA methylation analysis of more than 20,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0618U

Psychiatry (bipolar disorder), DNA methylation analysis of more than 10,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0619U

Pulmonary (chronic obstructive pulmonary disease [COPD]), DNA methylation analysis of more than 18,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0620U

Oncology (hepatocellular carcinoma), DNA methylation analysis of more than 5,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0621U

Infectious disease (Lyme borreliosis), DNA methylation analysis of more than 10,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0622U

Psychiatry (major depressive disorder), DNA methylation analysis of more than 20,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0623U

Autoimmune (multiple sclerosis), DNA methylation analysis of more than 5,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0624U

Hepatology (nonalcoholic steatohepatitis [NASH]), DNA methylation analysis of 5,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0625U

Endocrinology (osteoporosis), DNA methylation analysis of more than 5,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0626U

Neurology (Parkinson disease), DNA methylation analysis of more than 20,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0627U

Psychiatry (schizophrenia), DNA methylation analysis of more than 15,000 sites, whole blood, algorithm reported as positive or negative risk

Yes

0628U

Nephrology (kidney disease-related genetic conditions), genomic analysis, renal disease panel, saliva, DNA, next-generation sequencing of 449 genes, reported as pathogenic or likely pathogenic variants of uncertain significance or risk alleles

Yes

0629U

Infectious disease (tuberculosis), DNA, analysis of 1 target by PCR with clustered regularly interspaced short palindromic repeat (CRISPR)-based probe detection, plasma or serum, qualitative report as detected or not detected

Yes

0630U

Oncology (breast), mRNA, gene expression profiling by microarray of 80 genes (80 content and 465 housekeeping), utilizing formalin-fixed paraffin-embedded tissue (FFPE), algorithm reported as an index that is diagnostic of a molecular subtype (luminal, ba

Yes

A2040

Microlyte PainGuard, per sq cm

Yes >$750

A2041

Foundation DRS+ Duo, per sq cm

Yes

A2042

Foundation DRS+ Solo, per sq cm

Yes

A2043

BIOBRANE, per sq cm

Yes

A2044

BIOBRANE Glove, each

Yes

A2045

NovaShield or NovoGen Wound Matrix, per sq cm

Yes

A4318

Female external urinary collection cup, with or without ring attachment, per day

Yes >$750

A4479

Electronic transanal irrigation system, includes electronic pump, water reservoir, tubing, and accessories, without catheter, any type

Yes >$750

A6548

Accessory to custom gradient compression garment, silicone band, any size

Yes >$750

A8005

Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted

Yes

A8006

Powered, cable driven grip assist glove, hand, finger, includes pressure sensors, glove replacement only

Yes

A9294

Prescription digital cognitive and/or behavioral therapy, biofeedback, FDA cleared, per course of treatment

No

C1743

Scaffold, endovascular noncoronary, resorbable drug eluting, with delivery system (implantable)

No

C8007

Open implantation of hypoglossal nerve neurostimulator array and pulse generator, not requiring insertion of a separate distal respiratory sensor electrode or electrode array

No

C8008

Revision or replacement of hypoglossal nerve neurostimulator array including connection to existing pulse generator

No

C8009

Removal of hypoglossal nerve neurostimulator array and pulse generator

No

C8010

Percutaneous placement of permanent common carotid embolic protection device, including all system components and imaging guidance; bilateral

No

C8011

Open implantation of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver, including external power source and all system components

No

C8012

Revision or replacement of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver

No

C8013

Removal of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver

No

G0680

Detection and quantification of coronary artery calcium and/or aortic valve calcification from algorithmic analysis of computed tomography of the chest with report

No

G0681

Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area

No

G0682

Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute for a wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof

No

G0683

Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1%

No

G0684

Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; each additional 100 sq cm wound surface a

No

L2221

Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source

Yes

L5992

All lower extremity prosthesis, foot shell for modular foot/nonsolid ankle cushion heel (SACH) replacement only

Yes >$750

M0233

Intravenous infusion, tocilizumab-aazg, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO)

No

M0234

Intravenous infusion, tocilizumab-aazg, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO)

No

Q0238

Injection, tocilizumab-aazg, for hospitalized adult patients with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

No

Q4418

BioLab Membrane Wrap Flow, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4419

BioLab Membrane Wrap Lite Flow, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4421

BioLab Membrane Wrap Solo, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4422

A/C Wrap, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4423

BioLab Tri-Membrane Wrap Flow, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4424

Revive FT, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4425

Revive TL, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4426

DermaBind TL + or DermaBind TL X, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4427

DermaBind DL N, DermaBind DL +, or DermaBind DL X, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4428

DermaBind SL N, DermaBind SL +, or DermaBind SL X, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4429

DermaBind CH N or DermaBind CH X, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4435

Renati Membrane, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4436

Renati AC Membrane, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4437

Revival AC, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4438

Pretect, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4439

InstaGraft, per sq cm (add-on, list separately in addition to primary procedure)

No

Q4440

CuraMatrix, per sq cm (add-on, list separately in addition to primary procedure)

No

C9309

Injection, onasemnogene abeparvovec-brve, per treatment

Yes

C9818

Suzetrigine, oral, 1 mg

Yes

J0463

Injection, atropine sulfate (Fresenius Kabi and therapeutically equivalent), 0.01 mg

No

J1098

Articaine ophthalmic, 8% solution, 0.4 ml

No

J1164

Injection, diltiazem HCl in 0.72% sodium chloride, 0.5 mg

No

J1553

Injection, immune globulin (Yimmugo), 100 mg

Yes

J3404

Injection, zopapogene imadenovec-drba suspension, per therapeutic dose

Yes

J8502

Injection, aprepitant (Aponvie), 1 mg

Yes

J9003

Leuprolide injectable (Camcevi ETM), 1 mg

Yes

J9183

Gemcitabine intravesical system, 225 mg

Yes

J9277

Injection, pembrolizumab, 1 mg and berahyaluronidase alfa-pmph

Yes

J9278

Injection, carboplatin (Avyxa), 1 mg

No

J9601

Injection, linvoseltamab-gcpt, 1 mg

Yes

Q5161

Injection, denosumab-kyqq (Aukelso/Bosaya), biosimilar, 1 mg

Yes

Q5162

Injection, denosumab-nxxp (Bildyos/Bilprevda), biosimilar, 1 mg

Yes
Facebook
Twitter
LinkedIn
Instagram
Website
View this email in your browser
You are receiving this email because of your relationship with AmeriHealth Caritas Ohio. Please reconfirm your interest in receiving emails from us. If you do not wish to receive any more emails, you can unsubscribe here.

5525 Parkcenter Circle, Suite 100, Dublin, OH, 43017

|