Prior Authorization Requirement Changes Effective September 1, 2021 – UM AROW 1577

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

On September 1, 2021, Blue Cross NC prior authorization requirements will change for Healthy Blue + Medicare members covered by Blue Cross NC. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following codes:

• 0203U – autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness
• 0620T – endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed
• 33995 – insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only
• 64555 – percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
• 64575 – incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
• 81191 – NTRK1 (neurotrophic receptor tyrosine kinase 1) (for example, solid tumors) translocation analysis
• 81192 – NTRK2 (neurotrophic receptor tyrosine kinase 2) (for example, solid tumors) translocation analysis
• 81193 – NTRK3 (neurotrophic receptor tyrosine kinase 3) (for example, solid tumors) translocation analysis
• 81194 – NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (for example, solid tumors) translocation analysis

Availity, LLC is an independent company providing administrative support services on behalf of Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.

Prior authorization requirement changes effective September 1, 2021 – UM AROW 1577

• 81279 – JAK2 (janus kinase 2) (for example, myeloproliferative disorder) targeted sequence analysis (for example, exons 12 and 13)
• 81338 – MPL (MPL proto-oncogene, thrombopoietin receptor) (for example, myeloproliferative disorder) gene analysis; common variants (for example, W515A, W515K, W515L, W515R)
• 81339 – MPL (MPL proto-oncogene, thrombopoietin receptor) (for example, myeloproliferative disorder) gene analysis; sequence analysis, exon 10
• 81351 – TP53 (tumor protein 53) (for example, Li-Fraumeni syndrome) gene analysis; full gene sequence
• 81352 – TP53 (tumor protein 53) (for example, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (for example, 4 oncology)
• 81353 – TP53 (tumor protein 53) (for example, Li-Fraumeni syndrome) gene analysis; known familial variant
• 81529 – oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis
• 93241 – external electrocardiographic recording for more than 48 hours up to seven days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation
• 93242 – external electrocardiographic recording for more than 48 hours up to seven days by continuous rhythm recording and storage; recording (includes connection and initial recording)
• 93243 – external electrocardiographic recording for more than 48 hours up to seven days by continuous rhythm recording and storage; scanning analysis with report
• 93244 – external electrocardiographic recording for more than 48 hours up to seven days by continuous rhythm recording and storage; review and interpretation
• 93245 – external electrocardiographic recording for more than seven days up to 15 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation
• 93246 – external electrocardiographic recording for more than seven days up to 15 days by continuous rhythm recording and storage; recording (includes connection and initial recording)
• 93247 – external electrocardiographic recording for more than seven days up to 15 days by continuous rhythm recording and storage; scanning analysis with report
• 93248 – external electrocardiographic recording for more than seven days up to 15 days by continuous rhythm recording and storage; review and interpretation
• C1767 – generator, neurostimulator (implantable), nonrechargeable
• C1778 – lead, neurostimulator (implantable)
• C1787 – patient programmer, neurostimulator
• L8680 – implantable neurostimulator electrode, each

Prior authorization requirement changes effective September 1, 2021 – UM AROW 1577

Not all prior authorization requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Availity* Provider Portal at and on the provider website . Contracted and noncontracted providers who are unable to access Availity can call Provider Services at 844-895-8160 for prior authorization requirements.