Authorization Grid Detail, Effective February 1, 2020 Form

NYM, CHP and HealthierLife 1 V20.1-2/1/2020

Medicaid, Child Health Plus and HealthierLife (HARP) Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 02/01/2020

I. Out of Network: Any Medicaid, CHP and HealthierLife service provided by a non- participating provider/facility/physician requires authorization.

II. Inpatient Admissions: All inpatient admissions require an authorization. Fidelis Care does not require authorization of emergency room services or any emergent service required to provide stabilization of an emergent condition. Fidelis Care does require authorization of post stabilization services and inpatient admissions after emergency room services are completed. All facility admissions are reviewed for medical necessity.

A. All acute inpatient facility services - benefits are unlimited when medically necessary.

B. Inpatient Rehabilitation Services: (acute, sub-acute and skilled nursing rehabilitation) require prior authorization.

 1.  Medical rehabilitation can be completed at an acute or sub-acute level of care.

2. Inpatient substance abuse rehabilitation requires prior authorization.

   C. Transplants: All solid organ and bone marrow / tissue transplants require authorization at the time of the transplant evaluation.
   Includes but not limited to: 32850-32856, 33930-33945, 38204-38215, 38230-38242, 44133- 44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757.

   D. Breast Cancer Surgery Centers:
   Fidelis Care Medicaid members must receive mastectomy and lumpectomy procedure associated with a breast cancer diagnosis, at high volume facilities. This link provides information regarding New York State policies.

   http://www.nyhealth.gov/health_care/medicaid/quality/surgery/cancer/breast/.

   E. OASAS Licensed Inpatient Substance Use Disorder Treatment: Effective 01/01/2020: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services (Inpatient SUD) provided by facilities in New York State that are licensed, certified or otherwise authorized by OASAS and participating in Fidelis Care’s provider network are not subject to prior authorization review by Fidelis Care. In addition, Inpatient SUD services are not subject to concurrent utilization review during the first twenty-eight (28) days of the inpatient admission, provided that the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days of the admission. The facility may fax or email the OASAS Appendix A Notification

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NYM, CHP and HealthierLife 2 V20.1-2/1/2020 Form and OASAS LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org. All Inpatient SUD services require facilities to perform daily clinical review of the patient. This does not require a facility to conduct a LOCADTR concurrent review module every day. In addition, all Inpatient SUD facilities must periodically consult with Fidelis Care starting on or just prior to the fourteenth (14th) day of treatment to ensure that the facilities are using the LOCADTR tool to ensure that the inpatient treatment is medically necessary for the patient. Inpatient SUD services may be subject to utilization review after the 28th day from admission or upon discharge using the LOCADTR clinical review tool. Prior to the member’s discharge, facilities must provide the member and Fidelis Care with a written discharge plan as determined using the LOCADTR clinical review tool. Further, prior to discharge, facilities must indicate to Fidelis Care whether the services included in the discharge plan are secured or determined to be reasonably available. All services may be reviewed retrospectively to assess the clinical necessity of the care.

Facilities that are outside of New York State, facilities that are not licensed, certified or otherwise authorized by OASAS, and facilities that are outside of Fidelis Care’s provider network, continue to be required to request prior authorization review for Inpatient SUD services. All Inpatient SUD services provided by such facilities are subject to concurrent review throughout the admission.

Providers with questions regarding these changes are encouraged to call Fidelis Care, during regular business hours, at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

F. Elective Surgical Procedures:
Many surgical and medical procedures which are completed within 24 hours will not be approved at an in-patient level of care. These same services when billed as an out-patient level of care do not require authorization if performed within the Fidelis Care network. Such procedures include, but are not limited to, laparoscopic procedures, and thyroid surgery if completed within 24 hours from the onset of surgery. The link provides a list of inpatient only procedures:
List of Inpatient Only Procedures

G. Orthopedic Surgical Procedures and Spinal Surgical Procedures, performed
in both inpatient and outpatient settings, require prior authorization for dates of service
beginning 10/1/2019. Effective for dates of service rendered on or after 12/23/19, prior
authorization has been delegated to TurningPoint Healthcare Solutions, LLC. For a list of codes
requiring prior authorization, click here.

H. OMH Licensed Inpatient Mental Health Treatment Effective 01/01/2020: Inpatient mental health treatment for members under age 18 provided by OMH licensed hospitals in New York State that are participating in Fidelis Care’s provider network are not subject to prior authorization review by Fidelis Care. Fidelis Care will not conduct concurrent utilization review during the first 14 days of inpatient admissions provided that the facility: i) notifies Fidelis Care of both the admission and the initial treatment plan within two business days of the admission by completing the OMH developed “Two-Day Notification and Initial Treatment Plan” form and submitting

NYM, CHP and HealthierLife 3 V20.1-2/1/2020 it to Fidelis Care by fax (718-896-1784), or by email to MentalHealthAdmission@fideliscare.org; ii) performs daily clinical review of the patient, and iii) participates in periodic consultation with Fidelis Care to ensure that the facility is using the evidence-based and peer reviewed clinical review criteria utilized by Fidelis Care which is approved by OMH and appropriate to the age of the patient to ensure medical necessity. All services may be reviewed retrospectively using the clinical review criteria of the plan which is approved by the office of mental health.
Inpatient mental health services provided to members age 18 and older require prior authorization review by Fidelis Care and are subject to concurrent review throughout the admission. Out-of-State and Out-of-Network providers continue to be required to request prior authorization review for inpatient mental health treatment for members of all ages. All inpatient mental health services provided by such facilities are subject to concurrent review throughout the admission. Providers with questions regarding these changes are encouraged to call Fidelis Care, during regular business hours, at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

III.
Outpatient surgery: The following services require prior authorization:

A. Bariatric surgery: 43770-43775, S2083

B Blepharoplasty: 15820-15823

C. Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396

D. Skin surgery and other dermatological procedures: The auth requirement for many skin surgery treatments and repairs has been removed if performed in the office or outpatient facility (POS 11 and 22). The following codes will continue to require authorization if completed as ambulatory surgery (POS 24): 10040, 11300- 11313, 11400 - 11471, 11721 Only the following codes continue to require authorization for any place of service: 11200- 11201, 11719, 15769-15829, 17340-17999 E. Services for the following codes performed in freestanding ambulatory surgery centers billing with bill type 0831 require an authorization (10060, 11100, 11900 and 17000, 20600, 20605, and 20610). Note: CPT code 20610 is non-covered when billed with one of the following diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.9 F. Ear repair and ear piercing: 69300 and 69090 G. Eyelid & ocular surgery: 65760-65771, 65772-65775, 66987-66988, 67900-67911 H. Abdominoplasty, lipectomy, panniculectomy: 15830-15839, 15847, 15876-15879 I. Reduction mammoplasty: 19300, 19318 J. Facial cosmetic, septoplasty, rhinoplasty: 21120-21296, 30400-30450, 30460, 30465-30520, 30620-30802, 30999, 31298, C9749, Q2028 K. Vascular procedures i.e. vein stripping, ligation, ablation and sclerotherapy: 36465-36466, 36468-36479, 36482-36483, 37718-37785, and 37241-37244. L. Gender reassignment surgery: 55970, 55980 M. Sinuplasty: 31295, 31296, 31297 N. Spinal Surgery: 20932, 20933, 20934, 22867-22870, 62380. O. Esophageal sphincter augmentation: 43284 P. Certain outpatient orthopedic and spinal surgical procedures require prior authorization for dates of service beginning 10/1/2019. Effective for dates of service rendered on or after 12/23/19, prior authorization has been delegated to TurningPoint Healthcare Solutions, LLC. Refer to Section II – item # G above. For a list of codes requiring prior authorization, click

NYM, CHP and HealthierLife 4 V20.1-2/1/2020 here.

IV.
Behavioral Health - Outpatient services The authorization requirement has been removed from all outpatient behavioral health

services except the following, which will continue to require authorization: A. Psychological/Neuropsychological Testing: 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146. Authorization is required: All requests should be submitted on the Psychological/Neuropsychological testing request form.

B. Developmental Pediatric Testing:
96112, 96113. Authorization is required. Note: 96110 is a non-covered service

C. Outpatient ECT: 90870

D. Partial Hospitalization (Mental Health and/or Substance Abuse) Rate Codes 4349, 4350, 4351, 4352, 4353, 4354, 4355, 4356, 4357, 4358, 4359, 4360, 4361, 4362, 4363, Revenue code 912, 913. HCPCS code H0035 and S9484 Requests for members under 21 can be made by email chmmc@fideliscare.org, fax, (347) 690- 7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid. E. Intensive Outpatient Treatment No prior authorization needed for first seven days of service; additional service days do require authorization Revenue code 905, 906, or 912, CPT code 90899, S9480, HCPCS code H2013

F. Autism Spectrum Disorder (ASD): The State has expanded benefits for CHP members with ASD to include increased case management services, certain DME items to assist speech performance, and Applied Behavioral Analysis, a form of enhanced behavioral modification.

1. Authorization is required for DME speech generation equipment.
2. Authorization is required from Behavioral Health for Applied Behavioral Analysis. Attestation of the diagnosis of ASD must be provided, at the time of request, by a licensed physician or psychologist. G. Mental Health Continuing Day Treatment (H2012): the first 7 service days do not require authorization; additional service days do require authorization. Requests for members ages 18-20 can be made by email chmmc@fideliscare.org, fax, (347) 690- 7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid. H. Personalized Recovery Oriented Services (PROS): H2018, H2019 Requests for members ages 18-20 can be made by email chmmc@fideliscare.org, fax, (347) 690- 7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid. I. Assertive Community Treatment (ACT): H0040 Requests for members ages 18-20 can be made by email chmmc@fideliscare.org, fax, (347) 690- 7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid. J. Intensive Psychiatric Rehabilitation Treatment (IPRT): H2012 K. Substance Use Disorder Intensive Outpatient Treatment: S9480 no prior authorization needed for first seven days of service; additional service days do require authorization. L. Opioid Treatment Program Services: the first 30 service days do not require authorization; additional service days do require authorization M. Outpatient Substance Use disorder Rehabilitation Services: the first 14 service days do not require authorization; additional service days do require authorization.

NYM, CHP and HealthierLife 5 V20.1-2/1/2020 N. The following additional services are available if determined to be eligible through enrollment in the adult HealthierLife plan and in conjunction with an evidence based assessment. These services are categorized as adult Home and Community Based Services HCBS:

1. Psychosocial Rehabilitation; H2017
2. Community Psychiatric Support and Treatment (CPST); H0036
3. Habilitation and Residential Support Services; T2017
4. Empowerment Services (Peer Supports); H0038
5. Short Term Crisis Respite; (No prior auth required for access; auth required before 72 hours of stay); H0045
6. Intensive Crisis Respite; H0045
7. Family Support and Training; H2014
8. Pre-Vocational Services: T2015
9. Transitional Employment; T2019
10. Supported Employment; H2023, H2025
11. Education Support Services; T2013
12. Provider Travel Supplement; A0160 O. Children and Family Treatment & Support Services (CFTSS) Effective 1/1/2019, three Children and Family Treatment and Support Services became available to Medicaid recipients under age 21 who meet medical necessity criteria. The three services are as follows:
13. OLP - Other Licensed Practitioner (90791, H0004, H2011, 90882)
14. CPST – Community Psychiatric Supports and Treatment (H0036)
15. PSR- Psychosocial Rehabilitation (H2017) Effective 7/1/19, an additional CFTSS will be available to Medicaid recipients under age 21:
16. FPSS- Family Peer Support Services (H0038) Effective 1/1/20, two additional CFTSS will be available in Medicaid to recipients under age 21:
17. YPSS – Youth Peer Supports and Services (H0038)

18. CI – Crisis Intervention (H2001, S9484, S9485) There is no prior authorization or concurrent review for Crisis Intervention. For all other CFTSS, Fidelis Care will not conduct prior authorization review for the first 3 visits, however, concurrent review is required prior to the 4th visit. Providers must submit the CFTSS Authorization Request Form by email or fax, (347) 690-7362 prior to the 4th visit. Providers may also contact Fidelis by telephone at 1-888-FIDELIS (1-888-343-3547) and follow the prompts.

    P. Children’s BH Carve-In: Effective 7/1/19

    Name of Service Authorization Requirement Age Requirement Medicaid Benefit Status (New or Previously covered) Medicaid -SSI Benefit Status
    (New, Previously covered, Carve-In) OMH designated Serious Emotional Disturbance (SED) Clinic Services None Under 19 New New OMH Outpatient Services None Under 21 Previously covered New

NYM, CHP and HealthierLife 6 V20.1-2/1/2020 Psychiatric Services None Under 21 Previously covered New Psychological Services None Under 21 Previously covered New Partial Hospitalization Program Prior Auth, Concurrent Review Under 21 New New Assertive Community Treatment (ACT) Prior Auth, Concurrent Review 18-20 New New Continuing Day Treatment Prior Auth, Concurrent Review 18-20 New New Personalized Recovery Oriented Services (PROS) Prior Auth, Concurrent Review 18-20 New New Inpatient Psychiatric Services Prior Auth, Concurrent Review Under 21 Previously covered New Comprehensive Psychiatric Emergency Program None Under 21 Previously covered New Outpatient – Clinic None Under 21 New New Outpatient – Rehabilitation Programs Concurrent
Under 21 New New Opioid Treatment Program Services Concurrent
Under 21 New New Chemical Dependence Inpatient Rehabilitative Services Prior, Concurrent Under 21 Previously covered New

Requests for services listed above for members under age 21 can be made by email chmmc@fideliscare.org, fax (347) 690-7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid.

Q. Children’s Home and Community Based Services, Effective 10/1/19: The following additional services are available to members age 20 and younger, if determined to be HCBS-eligible by a Health Home or the Children and Youth Evaluation Service (C- YES):  Community Habilitation  Day Habilitation  Caregiver/Family Support and Services  Community Self Advocacy Training and Support  Prevocational Services - must be age 14 and older

NYM, CHP and HealthierLife 7 V20.1-2/1/2020  Supported Employment - must be age 14 and older  Respite Services (Planned Respite and Crisis Respite)  Palliative Care  Environmental Modifications  Vehicle Modifications  Adaptive and Assistive Equipment
 Youth Peer Support Services and Training
 Crisis Intervention

Requests for services listed above for members under age 21 can be made by email SMChildrensHCBS@fideliscare.org, fax (347) 690-7362 or by calling 1-888-FIDELIS (1- 888-343-3547) and following the prompts for Children’s Medicaid.

V. Outpatient and DME Services: The following services require prior authorization: A. Diagnostic testing

1. Sleep Studies, including Home Sleep Studies
2. Breast Cancer testing (BRCA) and other Genetic Testing (Note: Authorization is not required for CPT 81220, 81329 and 81336. CPT 81220 has a lifetime limit of 1. CPT 81329 and 81336 have a combined limit of 1 per lifetime.)
3. Wireless Capsule Endoscopy (91110, 91111)

4. Gastroenterology Procedures – The following procedures require authorization if

     performed in POS 19 and 22 when there is an office-based or ambulatory surgery center  
     available to provide the service: 43235, 43239, 43248, 45378, 45380, 45384,  
     45385, 46255, 46260, and 46270. 
     Authorization is not required for these services when performed in POS 11 or 24.

   B. Durable Medical Equipment: DME coverage information is available in the Medicaid DME Program Manual at:

   https://www.emedny.org/ProviderManuals/DME/index.aspx

   1. For Medicaid, supplies and disposable items are covered by Fidelis Care.
      Disposable items and supplies are not covered by Fidelis Care CHP lines of business. Sections 4.1 to 4.3 in the DME Manual describe the specific codes for Supplies that are covered and do not require authorization. For MLTC members only, the following supply codes require authorization: A4335, A4554, T4521-T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543 (*note this authorization requirement is effective 4/1/16) DME items for which Fidelis Care requires authorization
      Benefit limits as defined in the Medicaid DME Program Manual apply.

      C. Home Health Care: Home care approvals are based on the medical need for

      skilled services.

      1. Personal Care Services for Medicaid and Managed Long Term Care (MLTC-Fidelis Care at Home and MAP). All services require authorization and use of the following codes:

NYM, CHP and HealthierLife 8 V20.1-2/1/2020

Codes and Rates Effective up to 03/31/2018

Codes and Rates Effective 04/01/2018 & forward

Service Description Previous HCPCS Code Previous Service
Billing Units → New HCPCS Code New Service Billing Units Contract Note Regarding Change Nursing Assessment including PRI & Intense cases T1001 Per Visit

T1001 Per Visit No code or rate change Level I (housekeeping) T1019 Per 15 mins

S5130U1 Per 15 mins Code change only Level II T1020 Hourly Code

T1019U1 Per 15 mins Code and unit change Nursing Supervision G0162 One per visit

G0162 One per visit No code or rate change

2. Personal Emergency Response System (PERS) is a Medicaid and MLTC benefit and requires an authorization.

3. Consumer Directed Personal Assistance services (CDPAS) is a benefit for Medicaid and Medicare and requires authorization.

   D. Hospice: Effective October 1, 2013, Hospice requests for Medicaid members should
   be submitted to Fidelis Care. CHP requests also should continue to be submitted to
   Fidelis Care. For Medicaid members enrolled in Hospice prior to October 1, 2013,
   the services will be covered by Medicaid FFS until member is no longer enrolled in
   Hospice.

   E. Imaging Studies: The services below require authorization:

4. The first 4 OB ultrasounds can be performed without an authorization. Five or more ultrasounds for a normal pregnancy (dx code Z32.01, Z33.1, Z34.00-Z34.03, Z34.80- Z34.83, Z34.9-Z34.93)) require authorization. OB ultrasounds for a high risk pregnancy (dx code O09.00-O09.03, O09.1-O09.13, O09.211-O09.213, O09.219, O09.291- O09.293-O09.299-O09.33, O09.40-O09.43, O09.511-O09.513, O09.519, O09.521- O09.523, O09.529, O09.611-O09.613, O09.619, O09.621-O09.623, O09.629, O09.70- O09.73, O09.811-O09.813, O09.819, O09.821-O09.823, O09.829, O09.891-O09.893, O09.899-O09.93, O36.80X0-O36.80X5, O36.80X9) do not require authorization.
5. Radiology services require prior authorization through eviCore healthcare. A full list of CPT codes can be found at https://www.evicore.com/healthplan/fideliscare.
6. DXA Scans:
   Authorization is not required when the following services are billed: a. Women age > 65: one 77080 or 77081 every two years when accompanied by diagnosis code Z13.820) b. Men age > 70: one 77080 or 77081 every two years when accompanied by diagnosis code: Z13.820)

NYM, CHP and HealthierLife 9 V20.1-2/1/2020 c. Women age 51-64 years: one 77080 or 77081 every two years when accompanied by any of the diagnosis codes on the attached list. d. Men age 51-69 years: one 77080 or 77081 every two years when accompanied by any of the diagnosis codes on the attached list:
Requests for either CPT code for any other age group or any other diagnosis will require authorization.

F. Effective 10/1/2019, Outpatient Therapy, including services rendered in the home:
Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST): all services performed by a therapy provider after the initial evaluation will require prior authorization through National Imaging Associates (NIA). Excludes PT, OT, ST performed in an Inpatient setting, Emergency Room, Skilled Nursing Facility, or during an Observation stay.) Services rendered on or after 10/1/2019, require prior authorization*

*PT, OT, and ST initial evaluations do not require a prior authorization. However, all other billed procedure codes, even if performed on the same date as the initial evaluation date, will require authorization prior to billing.

Non-Therapy Providers (MD, DO, DPM, etc.) should request prior authorization for all services after the initial evaluation directly through Fidelis Care.

The Medicaid and MLTC benefit is limited to 20 visits per member for Occupational and
Speech Therapy per calendar year, and effective 7/1/18, 40 visits for Physical therapy
beginning with the calendar year 2018. There is no visit limit for CHP. Services received at

home are not included in this restriction.

G. Podiatry Services:

 Authorization is not required for podiatric services rendered to members with a confirmed     
 diagnosis of Diabetes Mellitus.  The Diabetes diagnosis must be included on the claim when  
 services are billed.  Podiatric services to members without a diagnosis of diabetes do require  
 authorization. For DME and orthotic codes in which authorization is required, Podiatrists will  
 require authorization even when supplied in the office, regardless of member diagnosis.

H. Therapeutic Services:

1. Phototherapy (96567, 96573-96574, 96900, 96910, 96912, 96913, 96920)
2. Hyperbaric Oxygen Therapy
3. Pain Management Codes (i.e. injections, TENS, therapeutic services):
   20526, 20550-20553, 21073, 27096, 62263-62264, 62273, 62280-62282, 62290, 62310- 62311, 62318-62319, 62320- 62327, 62370, 64400-64530, 64553-64595, 64600-64640, C1823, C9752, C9753 (for non-orthopedists only).
4. The following services are not covered for members with a diagnosis of Low Back Pain: a. Prolotherapy; b. Therapeutic facet joint steroid injections in the lumbar and sacral regions with or without CT fluoroscopic image guidance; c. Therapeutic injections of steroids into intervertebral discs; and d. Continuous or intermittent traction.

NYM, CHP and HealthierLife 10 V20.1-2/1/2020

5. Topical oxygen requires prior authorization.
6. Radiation Therapy services require prior authorization through eviCore healthcare. A full list of CPT codes can be found at https://www.evicore.com/healthplan/fideliscare.

7. Ambulatory continuous glucose monitoring: 95249. I. Long Term Home Health Care Services
   Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered with an authorization for Medicaid Managed Care enrollees who have transitioned from the Medicaid Fee-for-Services Long Term Home Health Care Program (LTHHCP) and were in receipt of these services at the time of transition into Medicaid Managed Care.

   J.
   Adult Day Health Care/AIDS Adult Day Health Care (ADHC/AADHC)

   Authorization is required for any new ADHC/AADHC patient. Prior authorization is

        also required for the initial assessment, up to two visits.  Members  already enrolled in an  
        ADHC/AADHC program as of 8/1/13 may remain in their current care plan for up to 90  
        days.  Requests for continuation of services beyond  that time period will be reviewed for  
        medical necessity.

   K. DME and pharmaceutical treatment for Erectile Dysfunction (note: these items

     and services are not covered for registered sex offenders): 54360, 54400-54402, 54405,  
     L7900

   L. Telehealth

     Authorization is required for G2010 and G2012.

   VI. Counseling Services A. Diabetes Self-Management Training (DSMT) Members are allowed 10 hours/20 units in a continuous 6-month period. These services must be provided by certified providers and no longer require authorization. Services are covered when billed with codes G0108 and G0109

   B. Asthma Self-Management Training (ASMT): Asthma self-management training services may be provided in individual sessions, or in group sessions of no more than eight patients. Authorization is not required for codes S9441, S9445, S9446, 98960-98962 when billed with diagnosis codes J45x
   Members, including pregnant women, with newly diagnosed asthma or with asthma and a medically complex condition (such as an exacerbation of asthma, poor asthma control, diagnosis of a complication, etc.) will be allowed up to ten (10) hours of ASMT during a continuous six- month period. Members with asthma who are medically stable may receive up to one (1) hour of ASMT during a continuous six-month period.

   C. Smoking Cessation Counseling (SCC): Billing for Medicaid members must meet the following criteria. No authorization is required.

8. Smoking cessation counseling will be reimbursed for up to 8 visits per calendar year using the sum of codes 99406 and 99407, and billed ONLY with DX code F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291.

   VII. New Technology/Experimental Treatment: Prior authorization is required and based on medical necessity.

NYM, CHP and HealthierLife 11 V20.1-2/1/2020

VIII. Services provided by outside vendors A. Orthodontic services are available for Medicaid members under age 21. Services require prior authorization by DentaQuest 1-800-516-9615.
B. Vision: Prior authorizations by Davis Vision 1-800-601-3383 C. Transportation Provider Manual (PDF)

IX. Pharmacy:
For quarterly updates to the formulary please check the website at: https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services A. Enteral Therapy-HCPCS codes B4034-B4162 describe the available enteral formulas or disposable items that require authorization. Benefit applies to: 1) Tube-fed individuals who can only obtain nutrition through a tube, 2) Individuals with inborn metabolic disorders requiring specific nutritional formulas not available through any other means, 3) Children under age 21 who require medical formulas due to mitigating growth and development factors. 4) Adults with a diagnosis of HIV infection, AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who  (a) require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, and have a body mass index (BMI) under 18.5 as defined by the Centers for Disease Control, up to 1,000 calories per day; or  (b) require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, and have a body mass index under 22 as defined by the Centers for Disease Control and a documented, unintentional weight loss of 5 percent or more within the previous 6 month period, up to 1,000 calories per day; or  (c) require total nutritional support, have a permanent structural limitation that prevents the chewing of food, and the placement of a feeding tube is medically contraindicated.

Pharmacy supplies do not require an authorization (supplies not covered for CHP, please refer to benefit plan).

B. These codes require authorization (with the exception of B4088). Please submit prior authorization requests to our Pharmacy Team electronically via fax (e-fax) to: 1-877- 533-2405.

C9054 lefamulin (Xenleta) C9047 caplacizumab-yhdp (Cablivi) C9055 brexanolone, G0516 insertion of implant G0517 removal of implant G0518 removal / reinsert implant J0129 abatacept (Orencia) J0135 adalimumab (Humira) J0178 aflibercept (Eylea) J0179 brolucizumab-dbll J0180 algalsidase beta (Fabrazyme) J0200 alatrofloxacin J0205 alglucerase
J0215 alefacept (Amevive) J0220 alglucosidase alfa (Myozyme) J0221 alglucosidase alfa (Lumizyme) J0222 patisiran (Onpattro) J0256 alpha 1-prot inhib NOS J0257 alpha 1-prot inhib (Glassia)
J0270 alprostadil (Prostin VR) J0275 alprostadil sup (Muse) J0401 aripiprazole ER inj (Abilify Maintena) J0490 belimumab (Benlysta)
J0517 benralizumab (Fasenra) J0565 bezlotoxumab (Zinplava) J0567 cerliponase alfa (Brineura) J0570 buprenorph impl (Probuphine) J0584 burosumab-twza (Crysvita) J0585 onabotulin tox A (Botox) J0586 abobotulin tox A (Dysport) J0587 rimabotulin tox B (Myobloc) J0588 incobotulinumtoxinA (Xeomin) J0593 lanadelumab-flyo (Takhzyro) J0596 c1 est inhib rec (Ruconest) J0597 c1 est inhib hum (Berinert) J0598 c1 est inhib hum (Cinryze) J0599 c1 est inhib hum (Haegarda) J0638 canakinumab (Ilaris) J0706 caffeine citrate inj
J0717 certolizumab pego (Cimzia)

NYM, CHP and HealthierLife 12 V20.1-2/1/2020 J0725 chorionic gonadotropin J0775 collagenase clostrid histol J0800 corticotropin (HP Acthar) J0841 crotalidae F(ab')2 (equine) J0885 epoetin alpha, non-ESRD (Epogen, Procrit) J0887 epoetin beta, ESRD (Mircera) J0888 epoetin beta, non-ESRD (Mircera) J0897 denosumab (Prolia, Xgeva) J1071 testosterone cypionate J1096 dexamethasone ophthalmic insert (Dextenza)
J1290 ecallantide (Kalbitor) J1300 eculizomab (Soliris) J1301 edaravone (Radicava) J1303 ravulizumab (Ultomiris) J1322 elosulfase alfa (Vimizim) J1325 epoprostenol (Flolan, Veletri) J1428 eteplirsen (Exondy) J1438 etanercept (Enbrel) J1442 filgrastim (Neupogen) J1454 fosnetupitant 235mg / palonosetron 0.25mg (Akynzeo) J1459 immune glob (Privigen) J1460 gamma glob (GamaSTAN) J1555 immune glob (Cuvitru) J1556 immune glob (Bivigam) J1557 immune glob (Gammaplx) J1559 immune glob (Hizentra) J1560 immune glob over 10cc (Gamastan) J1561 immue glob (Gamunex-C, Gammaked) J1562 immune glob (Vivaglobin) J1566 immune glob powder J1568 IVIG (Octagam) J1569 IVIG (Gammagard) J1572 IVIG (Flebogamma) J1575 immune glob / hyaluronidase (Hyqvia) J1595 glatiramer 20 mg
J1599 immune glob (Panzyga) J1602 golimumab (Simponi Aria) J1628 guselkumab (Tremfya) J1740 ibandronate (Boniva) J1742 ibutilide (Corvert) J1743 idursulfase (Elaprase) J1745 infliximab (Remicade) J1746 ibalizumab-uiyk (Trogarzo) J1786 imiglucerase (Cerezyme) J1826 interferon beta-1a 30 mcg

(Avonex) J1830 interferon beta-1b 0.25 mg

(Betaseron, Extavia) J1835 itraconazole
J1930 lanreotide (Somatuline) J1931 laronidase (Aldurazyme) J1950 leuprolide acet (Lupron Depot) J2170 mecasermin Increlex) J2182 mepolizumab (Nucala) J2323 natalilzumab (Tysabri) J2326 nusinersen (Spinraza) J2350 ocrelizumab (Ocrevus) J2353 octreotide depot (Sandostatin LAR Depot) J2354 octreotide non-depot J2357 omalizumab (Xolair) J2440 papaverin J2503 pegaptanib (Macugen) J2505 pegfilgrastim (Neulasta) J2507 pegloticase (Krystexxa) J2562 plerixafor (Mozobil) J2778 ranibizumab (Lucentis) J2786 reslizumab (Cinqair) J2787 riboflavin ophth (Photrexa) J2793 rilonacept (Aracalyst) J2796 romiplostim (Nplate) J2840 sebelipase alfa (Kanuma) J2941 somatropin J3031 fremanezumab-vfrm (Ajovy) J3110 teriparatide (Forteo) J3111 romosozumab (Evenity) J3121 testosterone enanthate J3145 testosterone undecanoate J3245 tildrakizumab (Ilumya) J3262 tocilizumab (Actemra) J3285 treprostinil (Remodulin) J3304 triamcin acet PF ER mic (Zilretta) J3316 triptorelin ER (Triptodur) J3355 urofollitropin (Bravelle) J3357 ustekinumab SC (Stelara) J3358 ustekinumab IV (Stelara) J3380 vedolizumab (Entyvio) J3385 velaglucerase alfa (Vpriv) J3396 verteporfin (Visudyne) J3397 vestronidase alfa-vjbk (Mepsevi) J3398 voretigene neparvovec-rzyl (Luxturna) J3490 unclassified drugs J3530 nasal vaccine inhalation J3570 laetrile amygdalin Vit B17 J3590 unclassified biologics J3591 unclassified drug / biologic ESRD J7170 emicizumab-kxwh (Hemlibra) J7175 factor X human (Coagadex) J7179 vWF recombinant (Vonvendi) J7180 factor XIII human (Corifact) J7181 factor XIII A-subunit recombinant (Tretten) J7182 factor VIII recombinant (NovoEight) J7183 vWF human (Wilate) J7185 factor VIII recombinant (Xyntha) J7186 VIII/VWF complex human

(Alphanate) J7187 vWF complex (Humate-P) J7188 factor VIII recombinant (Obizur) J7189 factor VIIa recombinant (Novoseven) J7190 factor VIII antihemophilic human (Hemofil M, Koate- DVI, Monoclate-P) J7191 factor VIII antihemophilic factor [porcine]) J7192 factor VII recom NOS J7193 factor IX non-recomb (AlphaNine/ Mononine) J7194 factor IX complex (Bebulin, Profilnine) J7195 factor IX recombinant (Ixinity/Benefix) J7198 anti-inhibitor (Feiba) J7199 hemophilia Clot Factor Noc J7200 factor IX recombinant (Rixubis) J7201 factor IX FC fusion recomb (Alprolix) J7202 factor IX album fusion recomb (Idelvion) J7203 factor IX recombinant glycopegylated (Rebinyn) J7205 factor VIII Fc fusion protein recombinant (Eloctate) J7207 factor VIII recomb pegyl (Adynovate) J7208 factor VIII recomb pegyl (Jivi) J7209 factor VIII recomb (Nuwiq) J7210 factor VIII recomb (Afstyla) J7211 factor VIII recomb (Kovaltry) J7308 aminolev acid top (Levulan) J7309 methyl aminolevulinate top J7311 fluocinolone acetonide, intravitreal implant (Retisert) J7312 dexamethasone intravitreal implant (Ozurdex) J7313 fluocinolone acetonide, intravitreal implant (Iluvien)

NYM, CHP and HealthierLife 13 V20.1-2/1/2020 J7314 fluocinolone acetonide, intravitreal implant (Yutiq) J7318 hyaluronan (Durolane) J7320 hyaluronan (Genvisc) J7321 hyaluronan (Hyalgan, Supartz, Visco-3) J7322 hyaluronan (Hymovis) J7323 hyaluronan (Euflexa)
J7324 hyaluronan (Orthovisc) J7325 hyaluronan (Synvisc, Synvisc- One) J7326 hyaluronan (Gel-One) J7327 hyaluronan (Monovisc) J7328 hyaluronan (Gelsyn) J7329 hyaluronan (Trivisc) J7331 hyaluronan (Synojoynt) J7332 hyaluronan (Triluron) J7336 capsaicin 8% patch
J7342 ciprofloxacin otic (Otipiro) J7401 Mometasone furoate sinus implant (Sinuva) J7504 anti-thymocyte glob equine J7515 cyclosporine 25mg oral J7516 cyclosporine 250mg inj J7517 mycophenolate mofetil 250mg (Cellcept) J7518 mycophenolic acid 180 mg (Myfortic) J7520 sirolimus (Rapamune) J7525 tacrolimus 5mg (Prograf) J7527 everolimus 0.25mg J7599 immunosuppress Drug Noc J7607 levalbuterol comp con
J7609 albuterol comp DME J7610 albuterol comp J7622 beclomethasone inh, comp J7624 bethamethasone inh J7626 budesonide (Pulmicort) J7629 bitolterol inh J7633 budesonide inhalation J7634 budesonide comp con J7635 atropine inj J7636 atropine inh J7637 dexamethasone inh J7638 dexamethasone inh UD J7639 dornase alfa (Pulmozyme) J7641 flunisolide inh J7642 glycopyrrolate inh J7643 glycopyrrolate inh J7659 isoproterenol inh J7677 revefenacin inh J7680 terbutaline inh J7681 terbutaline inh J7683 triamcinolone inh J7684 triamcinolone inh J7685 tobramycin inh J7686 treprostinil (Tyvaso) J8499 rx drug oral non-chemo J8510 busulfan (Myleran) J8515 cabergoline
J8520 capecitabine 150 mg J8521 capecitabine 500mg J8560 etoposide (Vepesid) J8562 fludarabine J8597 antiemetic oral J8600 melphalan (Alkeran) J8650 nabilone (Cesamet) J8655 netupitant 300mg, palonosetron 0.5mg (Akynzeo) J8700 temozolomide (Temodar) J8999 rx oral chemo J9022 atezolizumab (Tecentriq) J9023 avelumab (Bavencio) J9042 brentuximab (Adcetris) J9057 copanlisib (Aliqopa) J9118 calaspargase pegol-mknl (Asparlas) J9119 cemiplimab-rwlc (Libtayo) J9173 durvalumab Imfinzi) J9203 gemtuzumab (Mylotarg) J9204 mogamulizumab-kpkc (Poteligeo) J9210 emapalumab (Gamifant) J9217 leuprolide depot 7.5mg J9225 histrelin imp (Vantas) J9226 histrelin imp (Supprelin LA) J9228 ipilimumab (Yervoy) J9229 inotuzumab ozo (Besponsa) J9269 tagraxofusp (Elzonris) J9271 pembrolizumab (Keytruda) J9299 nivolimab (Opdivo) J9302 ofatumumab (Arzerra) J9311 rituximab hyaluronidase (Rituxan Hycela) J9312 rituximab (Rituxan) J9313 moxetumomab pasudotox-tdfk
(Lumoxiti) Q2041 axicabtagene (Yescarta) Q2042 tisagenlecleucel (Kymriah) Q3028 interferon beta-1a, SC (Rebif) Q4081 epoetin alfa ESRD (Epogen, Procrit) Q5103 infliximab-dyyb (Inflectra) Q5104 infliximab-abda (Renflexis) Q5109 infliximab-qbtx Ixifi) Q9991 buprenorphine ER <100mg (Sublocade) Q9992 buprenorphine ER >100mg

(Sublocade) S0122 menotropins S0126 follitropin alfa S0128 follitropin beta S0189 testosterone pellet (Testopel)

*authorization is not required for oncology indications

Note:
 J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326 J7327, J7328, J7329, J7331, J7332 are non- covered when billed with CPT code 20610 or 20611 or any of the following diagnosis: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.  J9035 (Avastin), J9355 (Herceptin), and J9306 (Perjeta) are available through the medical benefit without prior authorization (PA). Xolair is available through the medical benefit and requires PA. Clinical criteria for Xolair may be found on the provider portal.

X.
All services for “Unlisted” or “Temporary” Codes require authorization