CurrentAmeriHealthPolicy N/A

Precertification requirements for elective services

Lists services and items that require precertification for elective, non-emergency care and notes that precertification does not guarantee coverage; applies to AmeriHealth members (commercial and specified lines) and providers submitting requests. A medical code list is available on the payer's Medical Policy Portal.

Policy Summary

PayerAmeriHealth

PolicyPrecertification requirements for elective services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain precertification prior to elective, non-emergency services and verify member benefits, as precertification does not guarantee coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+major groups requiring precertification

Numerousdrugs listed

Multiplegenetic test categories

81400-81408+genetic procedure codes flagged

Services and Tests Requiring Precertification

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Catalog of services requiring precertification

Services and items requiring precertification (elective/non-emergency):

Catalog of service categories requiring precertification — provider must obtain precertification for listed elective/non-emergency services; precertification does not guarantee coverage and benefits are subject to member plan terms.

Inpatient services

Acute rehabilitation admissions
Elective surgical and nonsurgical inpatient admissions
Inpatient hospice admissions
Long-term acute care (LTAC) facility admissions
Skilled nursing facility admissions

Procedures

Bone graft substitutes and bone morphogenetic proteins for spine surgery
Cervical decompression with or without fusion
Cervical disc arthroplasty
Cochlear implant surgery
Hip arthroplasty
Hip arthroscopy and open procedures
Knee arthroplasty

Reconstructive and potentially cosmetic procedures

Blepharoplasty/ptosis repair
Bone graft, genioplasty, and mentoplasty
Breast procedures: reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion and removal of breast implants
Canthopexy/canthoplasty
Cervicoplasty
Chemical peels
Dermabrasion

Transportation

Elective (non-emergency) ground, air, and sea ambulance transportation

Interventional pain management

Epidural injection procedures and diagnostic selective nerve root blocks
Implanted spinal cord stimulators
Paravertebral facet injection/nerve block/neurolysis
Regional sympathetic nerve block
Sacroiliac joint injections

Radiation and related therapies (outpatient)

External beam including 2D, 3D conformal, IMRT, tomotherapy, IGRT, SBRT, SRS
Brachytherapy including LDR, HDR, and outpatient intra-operative techniques (IORT)
Hyperthermia
Neutron radiotherapy
Proton beam radiation therapy
Radio-labeled drugs used for radiation therapy (e.g., Radium Ra-223, ibritumomab tiuxetan)

Durable medical equipment (selected)

Bone growth stimulators (non-invasive) and other non-spinal electrical bone growth stimulation
Low-intensity ultrasound non-invasive bone growth stimulation
Spinal non-invasive electrical bone growth stimulation
Bone-anchored (osseointegrated) hearing aids; cochlear implants; bone conduction hearing aids
CPAP and bi-level (bi-PAP) devices and supplies
Electric, power, and motorized wheelchairs, including custom accessories

Other facility and specialty services

Medical foods
Hyperbaric oxygen therapy
In-lab/facility sleep studies
All transplant procedures (except corneal transplants)

Behavioral health and substance use

Inpatient mental illness/serious mental illness care
Partial hospitalization programs
Intensive outpatient mental illness care
Repetitive transcranial magnetic stimulation (rTMS)
Inpatient substance abuse treatment
Partial hospitalization programs for substance abuse
Intensive outpatient substance abuse treatment

Autism services

Applied behavioral analysis
In-network level of benefits for nonparticipating providers for non-emergent services unavailable in-network when plan lacks out-of-network benefit

Drugs and therapies requiring precertification

Alzheimer's disease agents (e.g., Kisunla, Leqembi)
Amyotrophic lateral sclerosis agents (e.g., debamestrocel, Qalsody)
Antineoplastic agents (extensive list of specific oncology drugs)
Anti-PD-1/PD-L1 monoclonal antibodies (selected agents listed)
Bone-modifying agents (selected agents listed)
Botulinum toxin agents (e.g., Botox)

This list is subject to change; providers may reference the complete medical code list on the Medical Policy Portal and contact Customer Service with questions.

Genetic/Genomic Precertification Criteria

The following categories of genetic and genomic tests require precertification:

Hereditary cancer syndromes — includes BRCA gene testing; Lynch syndrome; familial adenomatous polyposis; PTEN (Cowden) and general cancer panels

Hereditary heart diseases — includes Long QT syndrome testing; aortic dilation/aneurysm (Marfan-related) testing

Full gene analysis — examples: cystic fibrosis full gene sequencing and deletion/duplication; PMP22 full gene sequencing and deletion/duplication

Multi-condition and expanded carrier panels — includes expanded carrier screening, hearing loss panels, intellectual disability panels, Noonan spectrum panels

Specialty oncology tests — cancer gene expression or protein signature tests (e.g., OncotypeDX, MammaPrint, Afirma, Prosigna, HeproDX); tumor molecular profiling (e.g., FoundationOne, neoTYPE, OncoPlexDX); tissue of origin testing; PCA3 testing

Pharmacogenomic tests — CYP2D6, CYP2C9, CYP2C19 and specialized drug response gene panels (e.g., GeneSight); warfarin response testing; MGMT methylation analysis

Other specialty tests — coronary artery disease risk testing and heart disease risk tests (examples listed)

Genome-wide tests — microarray studies; whole exome testing; whole genome testing; mitochondrial genome or nuclear testing

Any genetic test for >1 gene or condition — tests described as panels or comprehensive require precertification

Any genetic test billed with non-specific or unlisted CPT codes — billed with CPT codes 81400-81408 or unlisted codes 81479, 81599, 84999 requires precertification

Precertification is not a determination of eligibility or a guarantee of payment; coverage/payment is contingent on member eligibility and plan terms.

Drug Precertification Criteria

Drug categories listed require precertification:

Miscellaneous therapeutic agents: Includes listed specialty agents such as Adakveo, Amvuttra, Crysvita, Soliris, Spinraza, Ultomiris, Veopoz, Vyepti, Xiaflex and others as specified in the drug lists.

Multiple sclerosis agents: Includes agents such as Briumvi, Lemtrada, Ocrevus, Tysabri, Tyruko.

Myasthenia gravis agents: Includes Imaavy, Rystiggo, Vyvgart, Vyvgart Hytrulo.

Tumor infiltrating lymphocyte (TIL) and T-cell therapies: Includes Amtagvi, Imdelltra, linvoseltamab, Tecelra.

Neutropenia and supportive agents: Includes Fylnetra, Granix, Grastofil, Lapelga, Neupogen, Nypozi, Nyvepria, Releuko, Rolvedon, Ryzneuta, Stimufend, Udenyca, Udenyca OnBody, Ziextenzo.

Antineoplastic and oncology agents: Extensive list of specific chemotherapy, targeted, and biologic oncology drugs enumerated in the policy (see drug lists).

Gene and cell therapies, replacement and editing therapies: Includes gene replacement/gene editing therapies and CAR-T therapies listed (examples: Hemgenix, Luxturna, Zolgensma; CAR-T agents: Abecma, Breyanzi, Carvykti, Kymriah, Yescarta, etc.).

Enzyme replacement and immunologic agents: Includes enzyme replacement therapies, IVIG/SCIG products, immunological agents listed in the drug sections.

This list is illustrative; consult the policy drug lists for full named agents and contact AmeriHealth or reference the Medical Policy Portal for the complete precertification drug code list.

Provider Requirements and Review Vendors

Prior Authorization

Precertification requirement and limitation

Precertification is required for many services performed on an elective, non-emergency basis. A precertification determination does not guarantee coverage — the member’s benefit plan terms, eligibility at time of precertification and service, and any applicable exclusions or limitations must be reviewed to determine coverage and payment. A published list of medical codes that require precertification is available on the AmeriHealth Medical Policy Portal for commercial members.

Applies to elective, non-emergency services
Precertification is not a guarantee of coverage or payment
Medical codes requiring precertification are published on the Medical Policy Portal

Prior Authorization

Third-party review for PA Medicare lines

Precertification review for PA Medicare lines of business is performed by Tango, an independent company. Providers should submit prior authorization requests for Medicare-product members through the Tango process and follow Tango’s submission instructions and documentation requirements.

PA Medicare lines: precertification review provided by Tango
Follow Tango submission instructions for Medicare prior authorizations

Prior Authorization

Precertification and Prenotification Requirements

Certain genetic and genomic tests and other categories of care require precertification and, in some cases, prenotification. Precertification is required for genome‑wide tests (microarray, whole exome, whole genome, mitochondrial genome or nuclear testing), any test that covers more than one gene or condition (panels/comprehensive tests), and any genetic test billed with non‑specific or unlisted CPT codes (e.g., 81400–81408, 81479, 81599, 84999). In addition, providers must prenotify AmeriHealth for categories of treatment where coverage determination prior to treatment is needed, including: potentially cosmetic surgical procedures; procedures, treatments, drugs, or devices considered new or emerging technology (including newly FDA‑approved infusion drugs); and services that may be experimental or investigational. Precertification is not a determination of eligibility or guarantee of payment; coverage is contingent on member eligibility and plan terms at the time services are provided. For questions, providers may call the Customer Service number on the member’s ID card or visit amerihealth.com/resources/for-providers/policies-and-guidelines/index.html.

Genome‑wide genetic tests (microarray, whole exome, whole genome, mitochondrial) require precertification
Any multi‑gene/condition genetic panel requires precertification
Any genetic test billed with CPT codes 81400–81408 or unlisted codes 81479, 81599, 84999 requires precertification
Prenotification required for: potentially cosmetic surgeries; new or emerging technology (including new infusion drugs); services that may be experimental/investigational
Precertification is not a guarantee of coverage; eligibility and plan terms apply
Provider resources: Customer Service on member ID card; AmeriHealth provider policies webpage

Note

Precertification Review Vendor

Precertification review vendors vary by service and line of business. Examples noted by AmeriHealth include: Carelon Specialty Health (performs certain precertifications), CareCore National, LLC d/b/a eviCore (provides precertification review for specified services), and Tango (handles precertification review for PA Medicare lines). Providers must use the appropriate vendor and follow that vendor’s submission process for prior authorization requests. Contact AmeriHealth Provider Services or refer to the Medical Policy Portal for the current list of vendor assignments and submission instructions.

Carelon Specialty Health performs specified precertifications
CareCore National, LLC d/b/a eviCore provides precertification review for certain services
Tango provides precertification review for PA Medicare lines
Check AmeriHealth Provider Services or the Medical Policy Portal for current vendor assignments and submission procedures

Key Definitions

inv-11: Precertification definition (scope and limitation)

ScopePrecertification applies to services performed on an elective, non-emergency basis and covers listed services that must be reviewed before scheduling.

PurposeA review process required prior to services to determine coverage eligibility; it does not guarantee payment or coverage.

LimitationCoverage and payment remain contingent on member eligibility and the specific terms, limitations, and exclusions of the member's benefit plan.

Code list referenceA published list of medical codes for services requiring precertification is available on the Medical Policy Portal.

inv-13: Prenotification definition and examples

DefinitionPrenotification is required for certain categories of treatment so providers know prior to treatment whether the service is covered.

Examples - potentially cosmeticAny surgical procedure that may be considered potentially cosmetic requires prenotification.

Examples - new/emerging technologyAny procedure, treatment, drug, or device that represents 'new or emerging technology,' including infusion therapy drugs newly approved by the FDA, requires prenotification.

Examples - experimental/investigationalServices that might be considered experimental or investigational require prenotification.

OpenPayer

Precertification requirements for elective services

Services and Tests Requiring Precertification

Codes and Coding Rules

Provider Requirements and Review Vendors

Key Definitions

81400-81408	Non-specific molecular pathology or multi-gene CPT codes (examples)
81479	Unlisted molecular pathology procedure code
81599	Unlisted diagnostic code
84999	Unlisted chemistry code