Prior Authorization Updates (April 2025)
3/18/2025
Effective in April 2025, the following codes will require Prior Authorization:
Code | Description | Effective Date |
|---|---|---|
B4162 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 4/20/2025 |
S9379 | Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem | 4/20/2025 |
B4155 | Code for Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit | 4/20/2025 |
0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device (if utilized), one or more needles | 4/20/2025 |
0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device (if utilized), two or more needles | 4/20/2025 |
B4162 | Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit | 4/20/2025 |
22899 | Spine surgery procedure | 4/20/2025 |
41899 | Other Procedures on the Dentoalveolar Structures | 4/21/2025 |
Please reach out to Provider Relations via our Provider Relations Inquiry Form with any questions regarding these changes.