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PA and Policy Updates

PA and Policy Updates 

Prior Authorizations and Policy Update Notifications Since September 1, 2024

For PA's and Policy notifications delivered prior to September 1 please see Updates page.

 

2025 Policy Updates

Buckeye is committed to continuously improving our overall payment integrity solutions. We previously provided notification in July 2023 that we would begin performing additional prepayment claim reviews using Optum’s Comprehensive Payment Integrity (CPI) tool.  This tool continues to evolve so Buckeye remains diligent in reviews and follow industry standards.   

If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.

If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews. 

If you have questions please contact Provider Services listed on our home page or your Provider Engagement Account Manager.

Editing Area 

Description 

Lines of Business 

Trauma Activation with No Ambulance Service​

Identifies outpatient claims with revenue codes for trauma response (Rev 681 – 689) w/ no claims for ambulance services with HCPCS codes between A0021 and A0999 for same member, same date of service. ​

Marketplace, Medicare, Medicaid 

High Dollar Hardware​

Identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws).​

Unsupported Lab Tests on High Dollar Claims​

Reviews high dollar lab claims potentially unsupported by an order from a qualified healthcare professional. ​

Cross-coder Outpatient Facility Surgical Claims​

Identifies outpt facility claims w/ surgical proc codes that do not match prof claim codes for similar services provided to same patient, same date of service. ​

Cross-coder Professional vs. Outpatient Facility Surgery Claims ​

Identifies prof claims w/surgical proc codes that do not match the outpt facility claim codes for similar services provided to same patient, same date of service.​

Digital Spike Analysis​

Reviews when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify required additional time and extra work was done to support billing this code.​

Upcoding of Incision and Drainage Codes​

Reviews claims billing incision and drainage (I&D) procedure codes suspected to be non-incision or lower-level I&D which may have been incorrectly submitted, reviewing simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081​

Misbilling of Third Order Selective Catheter Placement​

Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. ​

Policy CC.PP.057:   A physician or other qualified health professional may submit both a preventative E&M CPT® code and a problem oriented E&M CPT® code on the same date of service for the same patient. Once clinically validated, if the problem-oriented E&M represents a significant and separately identifiable E&M procedure or service, the problem-oriented procedure code will be reimbursed at a reduced rate.

Policy CC.PP.071:   Treatment Room and Specialty Services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting. The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus.

Treatment room services are outpatient services, furnished on hospital premises, which require the use of a bed, and periodic monitoring for a relatively brief episode of time in order to carry out certain procedures. The use of the treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room as patients can also recover in the treatment room. Operating rooms are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia.

Payment Policy CC.PP.052:   The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service. Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10-or 90-day global period when making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10-or 90-day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre-and post-operative work associated with the procedure.

The purpose of this policy is to ensure that the level of E&M service reported by the provider for emergency department (ED) E&M services reflects the level of services performed. There are three key components providers must consider when selecting the appropriate level of E&M service provided: history taking, physical examination and medical decision making.  When selecting the appropriate level of E&M service, all the key components must meet or exceed the stated requirements to qualify for a particular level of E&M service (i.e., office, new patient, inpatient hospital care, office consultations, emergency department services, etc.) See our Policy Website Page for more details.

Physician medical records should chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. See our Policy Website Page for details. 

Payment Policy CC.PP.067: Renal Hemodialysis 

Providers furnishing hemodialysis services are reimbursed up to three times per calendar week. If the provider bills for treatments in excess of this frequency, either in units or visits, the applicable service line will deny any units or visits above the three times per week limitation.

If a provider receives a claim denial for additional hemodialysis beyond the usual weekly maintenance dialysis due to the Member’s underlying condition, the dialysis provider may request a reconsideration or appeal accompanied by a medical justification. See Policy Website Page.

The purpose of this policy is to define payment criteria for newborn inpatient stays to be used in making payment decisions and administering benefits. Newborn inpatient stays are reimbursed by the Health Plan based on Medicare Severity Diagnosis Related Groups (MS-DRGs).

For newborn inpatient stays, assignment of a NICU-level DRG is dependent upon the exclusive billing of NICU revenue codes. When a claim reflects only non-NICU revenue codes (170/171 normal newborn stay), it will be reclassified and reimbursement adjusted to MS-DRG 795 in accordance with health plan policy requirements. See Policy Website.

Medicaid: EXfz (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration. 

Marketplace: EXhn (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration 

We are committed to continuously improving our overall payment integrity solutions to prevent overpayments due to waste or abuse. On July 1, 2023, we notified you that we would begin performing additional prepayment claim review using Optum’s Comprehensive Payment Integrity tool.  This tool continues to evolve, so we remain diligent in reviews and follow industry standards. The latest edit areas are shown below.

Optum CPI Amisys X0097 P0335                                         

Effective 9/1/2025 Optum will include edits for the following. 

Editing Area 

Description 

Lines of Business 

Critical Care Coding Requirements   

Review seeks to ensure appropriate critical care billing for illnesses or injuries.  

Marketplace, Medicare, Medicaid 

Percutaneous Nephrostolithotomy (PCNL) Procedures   

Review of professional and outpatient claims seeks to ensure documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure.   

If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.

If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews. 

If you have questions please contact Provider Services listed on our home page or your Provider Engagement Account Manager if you have any questions.

 

2025 Prior Authorizations - Effective in 2025

As of October 1, 2025, codes S5000 and S5001 will require prior authorization on any billed charges that exceed $500.

A breakdown of the S5000 and S5001 codes is as follows for your reference:

  • HCPCS code S5000 is a temporary national code used to identify a generic prescription drug. Part of the HCPCS level II codes, which are codes used for billing and reimbursement for healthcare services and supplies, the S5000 code is specifically used for generic medications that have been prescribed by a healthcare provider.
  • HCPCS code S5001 is a billing and insurance code used for brand name prescription drugs only, prescribed by a healthcare provider. It falls under the category of “miscellaneous medications and therapeutic substances,” as maintained by the Centers for Medicare & Medicaid Services (CMS).

Codes S5000 and S5001 should only be used when a more appropriate or specific code is not available.

As of October 1, 2025, prior authorization is required for Ambetter by Buckeye Health Plan providers billing HCPCS code H0019 (BHVAL HLTH; LNG-TERM RES PER DIEM).

Evolent (formerly New Century Health) manages prior authorizations for Centene for Medical Oncology, Radiation Oncology, Pediatric and Dose Optimization, and Cardiology.

Beginning October 1, 2025, the procedure codes included in this bulletin will require prior authorization through Evolent. This change applies to all Ambetter (Marketplace), Medicaid, and Medicare products offered by Centene.

If you have any questions regarding this update please contact your Provider Engagement representative.

Codes Requiring Prior Authorization Effective October 1, 2025

CODE

MEDICATION

DOSE

 

ANTI-EMETICS

 

J1456

INJECT FOSAPREPITANT NOT THERAP EQUIV J1453

1 MG

J1626

INJ GRANISETRON HYDROCHLORIDE

100 MCG

J2469

INJECTION PALONOSETRON HCL

25 MCG

Q0162

ONDAN 1 MG ORL NOT EXCEED 48 HR DOS

1 MG

Q0166

GRANISETRON HCL ORAL CHEMO ANTI-EMETIC

1 MG

 

BONE METS

 

J0897

DENOSUMAB INJECTION

 

J2430

INJ PAMIDRONATE DISODIUM

30 MG

J3489

ZOLEDRONIC ACID

1MG

 

CANCER TREATMENT

 

A9513

LUTETIUM LU 177 DOTATATE THERAPEUTIC

1 MCI

C9155

INJECTION EPCORITAMAB-BYSP

0.16 MG

C9163

INJECTION TALQUETAMAB-TGVS

0.25 MG

C9165

INJECTION ELRANATAMAB-BCMM

1 MG

J0202

INJECTION ALEMTUZUMAB

1 MG

J0594

INJECTION BUSULFAN

1 MG

J0640

INJ LEUCOVORIN CALCIUM PER

50 MG

J0641

INJECTION LEVOLEUCOVORIN NOS

0.5 MG

J0642

Injection, levoleucovorin (Khapzory)

0.5 mg

J0791

INJECTION CRIZANLIZUMAB-TMCA

5 MG

J0893

INJECTION DECITABINE NOT THR EQUIV TO J0894

1 MG

J0894

INJECTION DECITABINE

1 MG

J1050

MEDROXYPROGESTERONE ACETATE

 

J1246

INJECTION DINUTUXIMAB

0.1 MG

J1950

INJ LEUPROLIDE ACETATE PER

3.75 MG

J1952

LEUPROLIDE INJECTABLE CAMCEVI,

1 MG

J1954

INJECTION LA FOR DEPOT SUSPENSION

7.5 MG

J2860

INJECTION SILTUXIMAB

10 MG

J3240

INJ THYROTROPIN PROV 1.1 VIAL

.9 MG

J3315

INJ TRIPTORELIN PAMOATE

3.75 MG

J3316

INJECTION TRIPTORELIN EXTENDED-RELEASE

3.75 MG

J7308

AMINOLEVULINIC ACID HCI FOR TICL ADMIN, 20%/1UNIT DOSAGE FORM

354MG

J7502

CYCLOSPORINE, ORAL, SOL

 

J7504

LYMPHOCYTE IMMUNE/ANTITHYMOCYTE GLOBULIN

5ML EA

J7512

PDN IMMED RLSE/DELAY RLSE ORAL

1 MG

J7520

SIROLIMUS ORAL

1 MG

J7527

ORAL EVEROLIMUS

 

J8510

BUSULFAN, ORAL

2 MG

J8520

CAPECITABINE, ORAL

150 MG

J8521

CAPECITABINE, ORAL

500 MG

J8530

CYCLOPHOSPHAMIDE ORAL

25 MG

J8560

ETOPOSIDE ORAL

50 MG

J8600

MELPHALAN ORAL

2 MG

J8610

METHOTREXATE ORAL

2.5 MG

CODE

MEDICATION

DOSE

 

CANCER TREATMENT

 

J8700

TEMOZOLOMIDE ORAL

5 MG

J8705

Topotecan, oral

0.25 mg

J8999

PRESCRIPTION DRUG-ORAL-CHEMOTHERAPEUTIC-NOS

 

J9000

INJECTION DOXORUBICIN HCL

10 MG

J9015

ALDESLEUKIN INJECTION

 

J9017

INJECTION ARSENIC TRIOXIDE

1 MG

J9019

ERWINAZE INJECTION

 

J9021

INJECT ASPARAGINASE RECOMBINANT (RYLAZE)

0.1 MG

J9022

INJECTION ATEZOLIZUMAB

10 MG

J9023

INJECTION AVELUMAB

10 MG

J9025

INJECTION AZACITIDINE

1 MG

J9027

INJECTION CLOFARABINE

1 MG

J9029

IVES INSTAL NADOFARAGN FIRADENOVC-VNCG PER THR D

 

J9030

BCG LIVE INTRAVESICAL INSTILLATION

1 MG

J9032

INJECTION BELINOSTAT

10 MG

J9033

INJECTION BENDAMUSTINE HCL

1 MG

J9034

INJ. BENDEKA

1 MG

J9035

INJECTION BEVACIZUMAB

10 MG

J9036

INJECTION BENDAMUSTINE HYDROCHLORIDE

1 MG

J9037

Injection, belantamab mafodotin-blmf

0.5 mg

J9039

INJECTION BLINATUMOMAB

1 MCG

J9040

BLEOMYCIN SULFATE INJECTION

 

J9041

INJECTION BORTEZOMIB

0.1 MG

J9042

BRENTUXIMAB VEDOTIN INJ

 

J9043

CABAZITAXEL INJECTION

 

J9044

INJECTION BORTEZOMIB NOS

0.1 MG

J9045

INJECTION CARBOPLATIN

50 MG

J9046

INJ BORTEZOMIB NOT THER EQUIV TO J9041

0.1 MG

J9047

INJECTION, CARFILZOMIB,

1 MG

J9048

INJ BTZ FRESENIUS KABI NOT TX EQV TO J9041

0.1MG

J9049

INJ BORTEZOMB HOSPIRA NOT TX EQV TO J9041

0.1 MG

J9050

INJECTION CARMUSTINE

100 MG

J9051

Injection, bortezomib (MAIA), not therapeutically equivalent to J9041

0.1 mg

J9052

Injection, carmustine (Accord), not therapeutically equivalent to J9050

100 mg

J9055

INJECTION CETUXIMAB

10 MG

J9056

INJECTION BENDAMUSTINE HCL VIVIMUSTA

1 MG

J9057

Injection, copanlisib

1 mg

J9058

INJECTION BENDAMUSTINE HCL APOTEX

1 MG

J9059

INJECTION BENDAMUSTINE HCL BAXTER

1 MG

J9060

CISPLATIN INJECTION

10 MG

J9061

INJECTION, AMIVANTAMAB-VMJW

2 MG

J9063

INJECTION MIRVETUXIMAB SORAVTANSINE-GYNX

1 MG

J9064

Injection, cabazitaxel (Sandoz), not therapeutically equivalent to J9043

1 mg

J9065

INJ CLADRIBINE PER

1 MG

J9070

CYCLOPHOSPHAMIDE

100MG

CODE

MEDICATION

DOSE

 

CANCER TREATMENT

 

J9071

INJECTION CYCLOPHOSPHAMIDE AUROMEDICS

5 MG

J9072

INJECTION CYCLOPHOSPHAMIDE AVYXA

5 MG

J9098

CYTARABINE LIPOSOME INJ

 

J9100

INJECTION CYTARABINE

100 MG

J9118

INJECTION CALASPARGASE PEGOL-MKNL

10 UNITS

J9119

INJECTION CEMIPLIMAB-RWLC

1 MG

J9120

INJECTION DACTINOMYCIN

0.5 MG

J9130

DACARBAZINE

100 MG

J9144

INJECTION DARATUMUMAB 10 MG AND HYALURONIDASE FIHJ

 

J9145

INJECTION DARATUMUMAB

10 MG

J9150

INJECTION DAUNORUBICIN

10 MG

J9153

INJECTION LIPOSOMAL 1 MG DNR AND 2.27 MG CA

 

J9155

DEGARELIX INJECTION

 

J9171

DOCETAXEL INJECTION

 

J9172

INJECTION DOCETAXEL DOCIVYX

1 MG

J9173

INJECTION DURVALUMAB

10 MG

J9176

INJECTION ELOTUZUMAB

1MG

J9177

INJECTION ENFORTUMAB VEDOTIN-EJFV

0.25 MG

J9178

INJECTION, EPIRUBICIN HCI

2 MG

J9179

ERIBULIN MESYLATE INJECTION

 

J9181

INJECTION ETOPOSIDE

10 MG

J9185

FLUDARABINE PHOSPHATE INJ

 

J9190

INJECTION FLUOROURACIL

500 MG

J9196

INJ GEMCITABINE HCI NOT THR EQUIV J9201

200 MG

J9198

INJ GEMCITABINE HYDROCHLORIDE INFUGEM

100 MG

J9200

INJECTION FLOXURIDINE

500 MG

J9201

INJECTION GEMCITABINE HCL NOS

200 MG

J9202

GOSERELIN ACETATE IMPLANT PER

3.6 MG

J9203

INJ GEMTUZUMAB OZOGAMICIN

0.1 MG

J9204

INJECTION MOGAMULIZUMAB-KPKC

1 MG

J9205

INJ IRINOTECAN LIPOSOME

1 MG

J9206

INJECTION IRINOTECAN

20 MG

J9207

IXABEPILONE INJECTION

 

J9208

IFOSFAMIDE INJECTION

 

J9209

INJECTION MESNA

200 MG

J9210

INJECTION EMAPALUMAB-LZSG

1 MG

J9211

INJECTION IDARUBICIN HCL

5 MG

J9214

INTERFERON ALFA-2B INJ

 

J9217

LEUPROLIDE ACETATE FOR DEPOT SUSPENSION

7.5 MG

J9218

LEUPROLIDE ACETATE PER

1 MG

J9223

INJECTION LURBINECTEDIN

0.1 MG

J9227

INJECTION ISATUXIMAB-IRFC

10 MG

J9228

IPILIMUMAB INJECTION

 

J9229

INJECTION INOTUZUMAB OZOGAMICIN

0.1 MG

J9230

MECHLORETHAMINE HCL INJ

 

J9245

INJECTION MELPHALAN HCI NOS

50 MG

J9246

INJECTION MELPHALAN EVOMELA

1 MG

CODE

MEDICATION

DOSE

 

CANCER TREATMENT

 

J9247

Injection, melphalan flufenamide

1 mg

J9250

METHOTREXATE SODIUM

5 MG

J9255

INJ METHOTREXATE NOT THR EQV TO J9260

50 MG

J9258

INJ PTX PRO-BND PA TEVA NOT EQUIV TO J9264

1 MG

J9259

INJ PTX PRO-BND PA AMER REG NOT EQ J9264

1 MG

J9260

INJECTION METHOTREXATE SODIUM

50 MG

J9261

INJECTION NELARABINE

50 MG

J9262

Injection, omacetaxine mepesuccinate

0.01 mg

J9263

INJECTION, OXALIPLATIN

0.5 MG

J9264

INJECTION PACLITAXEL PROTEIN-BOUND PARTICLES

1 MG

J9266

PEGASPARGASE INJECTION

 

J9267

PACLITAXEL INJECTION

 

J9268

INJECTION PENTOSTATIN

10 MG

J9269

INJECTION TAGRAXOFUSP-ERZS

10 MCG

J9271

INJECTION PEMBROLIZUMAB

1 MG

J9272

INJECTION, DOSTARLIMAB-GXLY

10 MG

J9273

INJECTION, TISOTUMAB VEDOTIN-TFTV

1 MG

J9274

INJECTION TEBENTAFUSP-TEBN

1 MCG

J9280

MITOMYCIN INJECTION

 

J9281

MITOMYCIN PYELOCALYCEAL INSTILLATION

1 MG

J9285

Injection, olaratumab

10 mg

J9286

INJECTION GLOFITAMAB-GXBM

2.5 MG

J9293

INJ MITOXANTRONE HYDROCHLORIDE PER

5 MG

J9294

INJECTN PEMETREXED HOSPIRA NOT EQUIV J9305

10 MG

J9295

INJECTION NECITUMUMAB

1 MG

J9296

INJECTN PEMETREXED ACCORD NOT EQUIV J9305

10 MG

J9297

INJ PEMETREXED SANDOZ NOT THR EQUIV J9305

10 MG

J9298

INJECTION NIVOLUMAB AND RELATLIMAB-RMBW

3 MG/1 MG

J9299

INJECTION NIVOLUMAB

1 MG

J9301

OBINUTUZUMAB INJ

 

J9302

OFATUMUMAB INJECTION

 

J9303

PANITUMUMAB INJECTION

 

J9304

INJECTION PEMETREXED PEMFEXY

10 MG

J9305

INJECTION PEMETREXED NOS

10 MG

J9306

INJECTION, PERTUZUMAB

1 MG

J9307

PRALATREXATE INJECTION

 

J9308

INJECTION RAMUCIRUMAB

5 MG

J9309

INJECTION POLATUZUMAB VEDOTIN-PIIQ

1 MG

J9311

INJECTION RITUXIMAB 10 MG AND HYALURONIDASE

 

J9312

INJECTION RITUXIMAB

10 MG

J9313

Injection, moxetumomab pasudotox-tdfk

0.01 mg

J9314

INJECTION PEMETREXED TEVA NOT EQUIV J9305

10 MG

J9316

INJ PERTUZUMAB TRASTUZUMAB AND HYAL ZZXF PER

10 MG

J9317

INJECTION SACITUZUMAB GOVITECAN HZIY

2.5 MG

J9318

INJECTION ROMIDEPSIN NONLYOPHILIZED

0.1 MG

J9319

INJECTION ROMIDEPSIN LYOPHILIZED

0.1 MG

J9320

Injection, streptozocin

1 g

J9321

INJECTION EPCORITAMAB-BYSP

0.16 MG

CODE

MEDICATION

DOSE

 

CANCER TREATMENT

 

J9322

INJ PEMETREXED BLUEPOINT NOT EQUIV J9305

10 MG

J9323

INJ PEMETREXED DITROMETHAMINE

10 MG

J9324

INJECTION PEMETREXED

10 MG

J9325

INJ TALIMOGENE LAHERPAREPVEC

 

J9328

TEMOZOLOMIDE INJECTION

 

J9330

TEMSIROLIMUS INJECTION

 

J9331

INJECTION SIROLIMUS PROTEIN-BOUND PARTICLES

1 MG

J9340

INJECTION THIOTEPA

15 MG

J9345

Injection, retifanlimab-dlwr

1 mg

J9347

INJECTION TREMELIMUMAB-ACTL

1 MG

J9348

INJECTION NAXITAMAB-GQGK

1 MG

J9349

INJECTION TAFASITAMAB-CXIX

2 MG

J9350

INJECTION MOSUNETUZUMAB-AXGB

1 MG

J9351

TOPOTECAN INJECTION

 

J9352

INJECTION TRABECTEDIN

0.1MG

J9353

INJECTION MARGETUXIMAB-CMKB

5 MG

J9354

INJ, ADO-TRASTUZUMAB EMT

1 MG

J9355

INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR

10 MG

J9356

INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK

 

J9357

Injection, valrubicin, intravesical

200 mg

J9358

INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI

1 MG

J9359

INJECTION, LONCASTUXIMAB TESIRINE-LPYL

0.075 MG

J9360

INJECTION VINBLASTINE SULFATE

1 MG

J9370

VINCRISTINE SULFATE

1 MG

J9371

INJ, VINCRISTINE SUL LIP

1 MG

J9380

INJECTION TECLISTAMAB-CQYV

0.5 MG

J9390

VINORELBINE TARTRATE INJ

 

J9393

INJECT FULVESTRANT NOT THR EQUIV TO J9395

25 MG

J9394

INJ FUL FRESENIUS KABI NOT TX EQV TO J9395

25 MG

J9395

INJECTION, FULVESTRANT

25 MG

J9400

INJ, ZIV-AFLIBERCEPT

1 MG

J9600

PORFIMER SODIUM INJECTION

 

J9999

NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUGS

 

Q2017

Injection, teniposide

50 mg

Q2043

SIPLEUCEL-T AUTO CD54+

 

Q2050

DOXORUBICIN INJ

10 MG

Q5107

INJECTION BEVACIZUMAB-AWWB BIOSIMILAR

10 MG

Q5112

INJECTION TRASTUZUMAB-DTTB BIOSIMILAR

10 MG

Q5113

INJECTION TRASTUZUMAB-PKRB BIOSIMILAR

10 MG

Q5114

INJECTION TRASTUZUMAB-DKST BIOSIMILAR

10 MG

Q5115

INJECTION RITUXIMAB-ABBS BIOSIMILAR

10 MG

Q5116

INJECTION TRASTUZUMAB-QYYP BIOSIMILAR

10 MG

Q5117

INJECTION TRASTUZUMAB-ANNS BIOSIMILAR

10 MG

Q5118

INJECTION BEVACIZUMAB-BVZR BIOSIMILAR

10 MG

Q5119

INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE

10 MG

Q5123

INJECTION RITUXIMAB-ARRX BIOSIMILAR

10 MG

Q5126

INJ BEVACIZUMAB-MALY BIOSIMILAR (ALYMSYS)

10 MG

CODE

MEDICATION

DOSE

 

CANCER TREATMENT

 

Q5129

INJECTION BEVACIZUMAB-ADCD BIOSIMILAR

10 MG

S0108

MERCAPTOPURINE ORAL

50 MG

 

ESA

 

J0881

INJECTION DARBEPOETIN ALFA NON-ESRD USE

1 MCG

J0885

INJECTION EPOETIN ALFA FOR NON-ESRD USE

1000 U

J0888

EPOETIN BETA NON ESRD

 

J0896

INJECTION LUSPATERCEPT-AAMT

0.25 MG

Q5106

INJECTION EPOETIN ALFA-EPBX BIOSIMILAR

1000 U

 

IRON

 

J1439

INJ FERRIC CARBOXYMALTOS

1MG

J1750

INJ IRON DEXTRAN

 

J1756

INJECTION IRON SUCROSE

1 MG

J2916

INJ SODIM FERRIC GLUCONATE

12.5 MG

Q0138

FERUMOXYTOL, NON-ESRD

 

 

MYELOID GROWTH FACTOR

 

J1442

INJ FILGRASTIM EXCL BIOSIMIL

 

J1447

INJECTION TBO-FILGRASTIM

1 MCG

J1449

INJECTION EFLAPEGRASTIM-XNST

0.1 MG

J2506

INJECT PEGFILGRASTIM EXCLUDES BIOSIMILAR

0.5 MG

J2820

INJ SARGRAMOSTIN (GM-CSF)

50MCG

Q5101

INJECTION, ZARXIO

 

Q5108

INJECTION PEGFILGRASTIM-JMDB BIOSIMILAR

0.5 MG

Q5110

INJ FILGRASTIM-AAFI BIOSIMILR

1 MCG

Q5111

INJECTION PEGFILGRASTIM-CBQV BIOSIMILAR

0.5 MG

Q5120

INJECTION PEGFILGRASTIM-BMEZ BIOSIMILAR

0.5 MG

Q5122

INJECTION PEGFILGRASTIM-APGF BIOSIMILAR

0.5 MG

Q5125

INJECTION FILGRASTIM-AYOW BIOSIMILAR

1 MCG

Q5127

INJECTION PEG-FPGK STIMUFEND BIOSIMILAR

0.5 MG

Q5130

INJECTION PEG-PBBK FYLNETRA BIOSIMILAR

0.5 MG

 

SUPPORTIVE MEDICATION

 

C9047

INJECTION, CAPLACIZUMAB-YHDP

1 MG

C9113

INJECTION, PANTOPRAZOLE SODIUM, PER VIAL

 

C9293

Injection, glucarpidase

10 u

J0171

ADRENALIN EPINEPHRINE INJECT

 

J0185

INJECTION APREPITANT

1 MG

J0207

Injection, amifostine

500 mg

J0208

INJECTION SODIUM THIOSULFATE

100 MG

J0612

INJECTION CALCIUM GLUCONATE NOS

10 MG

J0613

INJECTION CAGLU NOT THERAP EQUIV TO J0612

10 MG

J0630

INJ CALCITONIN SALMON TO

400 U

J0780

INJ PROCHLORPERAZINE TO

10 MG

J0895

INJ DEFEROXAMINE MESYLATE

500 MG PER 5 CC

J1030

INJ METHYLPREDNISOLONE ACETATE

40 MG

CODE

MEDICATION

DOSE

 

SUPPORTIVE MEDICATION

 

J1040

INJ METHYLPREDNISOLONE ACETATE

80 MG

J1100

INJ DEXMETHOSON SODIM PHOSHATE

1 MG

J1190

INJ DEXRAZOXANE HYDROCHLORIDE PER

250 MG

J1200

INJ DIPHENHYDRAMINE HCL TO

50 MG

J1260

Injection, dolasetron mesylate

10 mg

J1302

INJECTION SUTIMLIMAB-JOME

10 MG

J1410

INJ ESTROGEN CONJUGATED PER 25 MG

 

J1437

INJECTION FERRIC DERISOMALTOSE

10 MG

J1448

INJECTION TRILACICLIB

1 MG

J1453

FOSAPREPITANT INJECTION

 

J1454

INJ FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG

 

J1459

INJ IVIG PRIVIGEN

500 MG

J1460

INJ GAMMA GLOBULIN IM

1 CC

J1554

INJECTION IMMUNE GLOBULIN ASCENIV

500 MG

J1555

INJECTION IMMUNE GLOBULIN

100 MG

J1556

INJ, IMM GLOB BIVIGAM

500MG

J1557

GAMMAPLEX INJECTION

 

J1558

INJECTION IMMUNE GLOBULIN XEMBIFY

100 MG

J1560

INJ GAMMA GLOBULIN IM OVER

10 CC

J1561

GAMUNEX-C/GAMMAKED

 

J1566

IMMUNE GLOBULIN, POWDER

 

J1568

OCTAGAM INJECTION

 

J1569

GAMMAGARD LIQUID INJECTION

 

J1572

FLEBOGAMMA INJECTION

 

J1575

INJ IG/HYALURONIDASE

100 MG IG

J1576

INJECTION IMMUNE GLOBULIN IV NON-LYOPH

500 MG

J1599

IVIG NON-LYOPHILIZED, NOS

 

J1627

INJ GRANISETRON EXT-RLSE

0.1 MG

J1630

INJ HALOPERIDOL TO 5 MG

 

J1643

INJECT HEPARIN SOD NOT THERAP EQUIV J1644

1000 U

J1720

INJ HYDROCORTISONE SODIUM SUCCINATE TO

100 MG

J1790

INJ DROPERIDOL TO 5 MG

 

J1930

INJECTION LANREOTIDE

1 MG

J1932

INJECTION LANREOTIDE

1 MG

J2150

INJ MANNITOL 25% IN 50 ML

 

J2212

METHYLNALTREXONE INJECTION

 

J2353

INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION

1 MG

J2354

INJ OCTREOTIDE NON-DEPOT FORM SUBQ/IV INJ

25 MCG

J2405

INJ ONDANSETRON HCL PER 1 MG

 

J2425

INJECTION PALIFERMIN

50 MCG

J2550

INJ PROMETHAZINE HCL TO 50 MG

 

J2562

PLERIXAFOR INJECTION

 

J2765

INJ METOCLOPRAMIDE HCL TO 10 MG

 

J2780

INJECTION, RANITIDINE HYDROCHLORIDE

25 MG

CODE

MEDICATION

DOSE

 

SUPPORTIVE MEDICATION

 

J2783

INJECTION, RASBURICASE

0.5 MG

J2790

RHO D IMMUNE GLOBULIN INJ

 

J2792

INJ RHO D IMMUNE GLOBULIN IV HUMAN

100 IU

J2796

ROMIPLOSTIM INJECTION

 

J2797

Injection, rolapitant

0.5 mg

J2920

INJ METHYLPREDNISOLONE SODIUM SUCCINATE TO 40 MG

 

J2930

INJ METHYLPREDNISOLONE SODIUM SUCCINATE TO 125MG

 

J3410

INJ HYDROXYZINE HCL TO 25 MG

 

J3411

INJECTION, THIAMINE HCI

100 MG

J3420

INJ VITAMIN B-12 CYANOCOBALAMIN TO 1000 MCG

 

J3430

INJ PHYTONADIONE (VIT K) PER 1 MG

 

J3471

INJECTION HYALURONIDASE OVINE PRESERVATIVE FREE /1 USP UNIT UP TO 999

 

J3475

INJECTION, MAGNESIUM SULFATE, PER 500 MG

 

J3480

INJECTION, POTASSUIM CHLORIDE, PER 2 MEQ

 

J3490

UNCLASSIFIED DRUGS

 

J3590

UNCLASSIFIED BIOLOGICS

 

J7510

PREDNISOLONE ORAL PER 5 MG

 

J7515

CYCLOSPORINE, ORAL 25 MG

 

J8499

PRESCRIPTION DRUG-ORAL-NON-CHEMOTHERAPEUTIC-NOS

 

J8501

APREPITANT ORAL

5 MG

J8540

DEXAMETHASONE ORAL

0.25 MG

J8655

NETUPITANT 300 MG AND PALONOSETRON 0.5 MG ORAL

 

J8670

ROLAPITANT ORAL

1MG

J9216

INTERFERON GAMMA 1-B INJ

 

P9045

INFUSION, ALBUMIN (HUMAN), 5%, 250 ML

 

P9046

INFUSION, ALBUMIN (HUMAN), 25%, 20 ML

 

P9047

INFUSION, ALBUMIN (HUMAN), 25%, 50 ML

 

Q0163

DIPHENHYDRAMINE HCL ORAL CHEMO ANTI-EMETIC

50 MG

Q0164

PROCHLORPERAZINE MALEATE ORAL ANTI-EMETIC

5 MG

Q0167

DRONABINOL ORAL APPRVD CHEMO ANTI-EMETIC

2.5 MG

Q0169

PROMETHAZINE HCL ORAL CHEMO ANTI-EMETIC

12.5 MG

Q0177

HYDROXYZINE PAMOATE 25 MG ORAL CHEMO ANTI-EMETIC

 

Q0180

Dolasetron mesylate, 100 mg, oral, FDA-approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment

 

S0176

HYDROXYUREA, ORAL

500MG

Service Category

 

PA Rule

Services

Procedure Codes

DME Services

No PA Required

Equipment Accessories

E0953, K0019, K0045, K0052

Wheelchairs

E0954, E0956, E0957, E0973, E1028, E2209, E2210, E2365, E2366, E2367, E2603, E2604, E2615, K0733, K0739

Home Services

No PA Required

Home Management

G0156

Sleep Medicine

No PA Required

Sleep Studies

95805

Surgery Procedures

No PA Required

Vascular

36471

Transportation Services

PA Required

Medical Transportation

A0431, A0436

No PA Required

Medical Transportation

A0434

Service Category

 

PA Rule

Services

Procedure Codes

DME Services

No PA Required

Wheelchairs

K0739

Drug Codes

PA Required

Medications

Q0138, Q0139

No PA Required

Injections

J0640

Genetic Analysis

PA Required

Genetic Testing

81420

Surgery Procedures

PA Required

Digestive System

43281, 43282, 49329

Male Genitalia

55866

Musculoskeletal System

28308

No PA Required

Facial, Cranial and TMJ Procedures

21230

Vascular

36476

 

Service Category

 

PA Rule

Services

Procedure Codes

Behavioral Health

PA Required

Treatment Services

90867, 90868

No PA Required

Treatment Services

97157

Cardiovascular

PA Required

Cardiovascular Tests

93623

Heart Surgery

93656

DME Services

PA Required

Incontinence Supplies

T4521, T4522, T4523, T4524

Nutritional Services

B4158, B4159, B4160, B4161

Orthotic and Prosthetic

L1833

No PA Required

Equipment and Accessories

E1392, K0043

Drug Codes

PA Required

Injections

J1437, J3490

Medications

Q0138, Q0139

Genetic Analysis

PA Required

Genetic Testing

81220, 81420

No PA Required

Genetic Testing

81244, 81331

Hearing Services

PA Required

Implants and Supplies

L8614, V5261

Home Services

No PA Required

Home Management

S5160, S5161

Infusion Services

S5498, S9500, S9501, S9502

Laboratory

No PA Required

Pathology

81270

 

 

Other Medical Services

 

PA Required

Surgical Supplies

A4554

No PA Required

Acupuncture

97810, 97811, 97813

Other Services

97010, 97014, 97032, 97035, 97150

Speech Therapy

92508

Wound Care

A6549

Physical Medicine

PA Required

Orthotic and Prosthetic

Q4101, Q4121, Q4160, Q4186, Q4195, Q4196

Physician Services

No PA Required

Education Services

S9140

Skin Procedures

PA Required

Muscle Flap Procedures

15734

No PA Required

Skin Grafts

14020, 14021

 

 

Surgery Procedures

 

 

 

 

 

PA Required

 

 

PA Required

Cardiovascular System

33285, 37220, 37221, 37225, 37228, 37229 37230, 37231, 37243

Digestive System

49329, 49505, 49591, 49593, 49595, 49650

Female Genitalia

58661, 58662

Integumentary System

19301

Male Genitalia

54360

Nervous System

64999

No PA Required

Vascular

36479

Transportation Services

PA Required

Medical Transportation

A0428, A0431, A0436

Buckeye Health Plan is continuously reviewing our Prior Authorization requirements and work to ensure our provider partners find our processes straightforward.  Buckeye wanted to announce that the Prior Authorization is being turned OFF for S5000-Script drug generic for Medicaid.   

It is also important to note that there is a prior authorization in place for all providers for S5001-Script drug brand name.  The Health Plan sees this code come through our claims system without a Prior Authorization often, which will lead to unnecessary denials, and this newsletter is serving as a reminder that S5001 DOES require a Prior Authorization for All providers.   

Updated Prior Authorization requirements for code G0483 - DRUG TEST DEF 22+ CLASSES.  Buckeye health Plan will align with OAC rule 5160-11-11, stating prior authorization is needed.  Currently, our system is set up as a conditional Prior Auth above 12 visits per year and this will be changed from the conditional Prior authorization requirement to “yes” for all providers.  This change will take effect 10/1/2025.

Important change to our pre-authorization requirements for certain laboratory codes, effective immediately.

Updated Pre-Authorization Guidelines

CPT Codes 80305–80307 (Presumptive Drug Testing):

  • Non-Participating Providers: Pre-authorization is required for all services.
  • Participating Providers: Pre-authorization is required after 30 visits per calendar year.

HCPCS Codes G0480–G0483 (Definitive Drug Testing):

  • Non-Participating Providers: Pre-authorization is required for all services.
  • Participating Providers: Pre-authorization is required after 12 visits per calendar year.

These updates are being implemented to support appropriate utilization and ensure the delivery of high-quality, cost-effective care.

Action Required

Please ensure your practice management and billing teams are aware of these changes and incorporate the updated requirements into your pre-authorization workflows.

Questions?

If you have any questions regarding this update or how it may affect your practice, please contact our Provider Services team at (866) 246-4356.

In April of 2025, we previously notified you that the Prior Authorization Code Updates listed below effective July 1, 2025. The effective date for this Prior Authorization Code Updates is now September 1, 2025.

S1040: Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

37229: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, 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

36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

31276: Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed

31295: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa

31298: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia

31296: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

19371: Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

S9123: Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)

E0466: Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)

B4105: In-line cartridge containing digestive enzyme(s) for enteral feeding, each

L5856:  Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type

64555: Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

L5968:  Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature

L0648:  Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0637:  Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

E0637: Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels

15847: Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)

E2370: Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only

E0641: Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels

K0801: Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds

E2375: Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only

The following codes will no longer require prior authorization:

G0268: Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing

If you have questions, please contact Provider Services.

Procedure Code

Procedure Code Description

New Standard

Line of Business

S5001

SCRIPT DRUG BRAND NAME

Prior Authorization will remain in place and claims configuration will align for appropriate payment

Medicaid

97161

PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS

Prior authorization for non par providers after 15 visits

Medicaid

97162

PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS

Prior authorization for non par providers after 15 visits

Medicaid

E0784

EXTERNAL AMBULATORY INFUSION PUMP; INFUSION

Prior authorization for all providers

 

E0260

HOSP BED SEMI-ELEC W/ANY RAILS W/MATTRESS

Prior authorization for all providers

 

Wellcare by Allwell requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Buckeye Health Plan.

We are committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.  Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.       

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool

Effective July 1, 2025, the following are changes to prior authorization requirements. 

Service CategoryPA RuleServicesProcedure Codes
Durable Medical EquipmentNo PA Required

Supplies & Devices

Beds

Neurostimulators

Equipment & Assessories

Wheelchairs

 

 

A9279, A9900

E0184

E0730


E0953

E0954, E0956, E0973, E0990, E1038, E2210, E2359, E2361, E2363, E2365, E2607, E2624, K0019, K0043, K0077, K0733

Home ServicesNo PA RequiredDialysis Services99512
Medical SuppliesNo PA RequiredSuppliesA4657
Other Medical ServicesNo PA RequiredWound Care97605, 97606
Physician ServicesNo PA RequiredDialysis Services
Neurological Tests
90989
95972
Surgery ProceduresPA RequiredSkin GraftsQ4205

Effective July 1, 2025, the following codes will require prior authorization to be submitted to Buckeye Health Plan.

S1040: Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

37229: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, 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

36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

31276: Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed

31295: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa

31298: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia

31296: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

19371: Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

S9123: Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)

E0466: Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)

B4105: In-line cartridge containing digestive enzyme(s) for enteral feeding, each

L5856:  Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type

64555: Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)

L5968:  Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature

L0648:  Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0637:  Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

E0637: Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels

15847: Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)

E2370: Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only

E0641: Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels

K0801: Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds

E2375: Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only

The following codes will no longer require prior authorization:

G0268: Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing

If you have questions, please contact Provider Services.

Effective July 1, 2025, the following codes will require prior authorization to be submitted to Ambetter from Buckeye Health Plan.

31276: Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed

31298: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia

J1439:  Injection, ferric carboxymaltose, 1 mg

31295: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa

31296: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium

36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

Q0138: Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)

If you have questions, please contact Provider Services.

Effective February 1, 2025, Buckeye Health Plan will be changing prior authorization requirements for the following codes:

Procedure Code

Procedure Code Description

 

 

New Standard

 

Line of Business

11042

Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

Pre-authorization is required after 12 visits for All Providers

Medicaid

11043

Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

Pre-authorization is required after 12 visits for All Providers

Medicaid

 

2024 Policy Updates


New Payment Policy: Leveling of Care: Evaluation and Management Overcoding Effective 12-1-24 (All Products)

Payment Policy CC.PP.066: Physician medical records should chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. See our Policy Website Page for full details. 

 

2024 Prior Authorizations Effective in 2024

Procedure Code

Procedure Code Description

New Standard
Line of Business

19303

MASTECTOMY, SIMPLE, COMPLETE

Pre-authorization is required for All Providers

Medicaid