Precertification requirements for elective services
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Defines services and items that require precertification for elective, non-emergency care and notes that precertification does not guarantee coverage; applies to AmeriHealth members per plan benefits. A list of specific services, procedures, equipment, and genetic tests requiring precertification is provided.
No material clinical or coverage changes in this revision.
Services and Items Requiring Precertification
Genetic testing categories
Genetic tests requiring precertification include the following categories and examples:
ALL of the following
Hereditary cancer syndromes
- BRCA gene testing (breast and ovarian cancer syndrome)
- Lynch syndrome gene testing
- Familial adenomatous polyposis gene testing
- PTEN gene testing (Cowden syndrome)
- General cancer type panels (such as colon, breast, or neuroendocrine cancers)
Hereditary heart diseases
- Long QT syndrome gene testing
- Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome)
Other full gene analysis testing
- Cystic fibrosis full gene sequencing and deletion/duplication analysis
- PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy)
Tests for many genetic disorders simultaneously
- Expanded carrier screening panels (e.g., Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening)
- Hearing loss panels
- Intellectual disability panels
- Noonan spectrum disorders 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 (for cancer of unknown primary)
- PCA3 testing for prostate cancer
Pharmacogenomic tests
- Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19)
- Specialized drug response gene panels (e.g., Assurex GeneSight®, GeneTrait, Genecept®)
- Warfarin response testing
- MGMT methylation analysis for glioblastoma
Other specialty tests
- Coronary artery disease risk testing (e.g., CorusCAD®, CardioIQ®, APOE, ACE, KIF6)
- Heart disease risk testing (e.g., CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR)
Genome-wide tests
- Microarray studies
- Whole exome testing
- Whole genome testing
- Mitochondrial genome or nuclear testing
Specialty drug categories and agents
Specialty drugs and biologics requiring precertification for commercial members (partial list):
ALL of the following
Alzheimer's Disease agents
- Kisunla™ §
- Leqembi™ §
Amyotrophic lateral sclerosis agents
- debamestrocel*
- Qalsody ®§
Antineoplastic agents
- Abraxane ®
- Adcetris ®
- Adstiladrin ®
- Alymsys ® (except for ophthalmological conditions)
- Anktiva ®
- Avastin ® (except for ophthalmological conditions)
- Avzivi ®
- Azedra ®†
- Bizengri ®
- Blincyto ®
- Columvi
- Cyramza ®
- Darzalex ®
Anti PD-1/PD-L1 human monoclonal antibodies
- Bavencio ®
- balstilimab*
- camrelizumab*
- Imfinzi™
- Jemperli
- Keytruda ®
Bone-modifying agents
- Aukelso ®
- Bildyos ®
- Bilprevda ®
- Bomyntra
- Bosaya ®
- Connexence ®
- Evenity ®
Botulinum toxin agents
- Botox ®
CAR-T therapies
- Abecma™
- Breyanzi ®
- Carvykti™
- Kymriah™
Duchenne Muscular Dystrophy agents
- Amondys 45 §
- Exondys 51 §
- Viltepso ®§
- Vyondys 53 §
Endocrine/metabolic agents
- Acthar H.P. ®
- Lutathera ®†
- Sandostatin ® LAR
Enzyme replacement agents
- Adzynma
- Aldurazyme ®
- Brineura™
- Cerezyme ®
Gene replacement/gene editing therapies
- Casgevy ®
- Elevidys™
- Hemgenix ®
Hyaluronate acid products
- Cingal ®
- Durolane ®
- Euflexxa™
All listed brands and their generic equivalents or biosimilars require precertification; list is subject to change and applies to commercial plans.
Drugs and therapeutic classes requiring precertification or special handling
This section enumerates therapeutic categories and specific drugs subject to precertification or special handling:
ALL of the following
Gene replacement / gene editing therapies**
- Casgevy ®
- clemidsogene lanparvovec*
- Elevidys™
- etuvetidigene autotemcel*
- Hemgenix ®
Hyaluronate acid products
- Cingal ®
- Durolane ®
- Euflexxa™
- Gel-One ®
- Gelsyn-3™
Immunological agents
- Actemra ® IV
- Avsola™
- Benlysta ® IV
- Cosentyx ® IV
- Entyvio™ IV
Multiple sclerosis agents**
- Briumvi™
- Lemtrada ®
- Ocrevus™
Myasthenia gravis agents**
- Imaavy ®
- Vyvgart ®
Neutropenia agents
- Fylnetra™
- Granix ®
- Neupogen ®
- Udenyca ®
Ophthalmic agents
- Ahzantive ®
- Beovu ®
- Eylea ®
- Lucentis ®
Pulmonary arterial hypertension agents**
- Flolan ®
- Remodulin ®
- Tyvaso ®
Respiratory agents
- Cinqair ®
- Synagis
- Xolair ®
Respiratory enzymes (alpha-1 antitrypsin)**
- Aralast
- Glassia™
- Prolastin ®
Tumor-infiltrating lymphocyte (TIL) and T-cell Therapies **
- Amtagvi™
- Imdelltra™
- linvoseltamab*
Miscellaneous therapeutic agents
- Adakveo ®
- Amvuttra™
- Crysvita ®
- Enjaymo™
- Evkeeza™
Precertification applies to all drugs classified under each header, including unlisted brand/generic names and biosimilars; precertification review for items marked ** is provided by eviCore (CareCore). Some listed agents or classes may be subject to group-level exclusions.
Codes Related to Precertification
| Refer to published medical code list on Medical Policy Portal for services requiring precertification. |
Precertification Actions, Reviewers, and Notes for Providers
Precertification required for elective/non-emergency services
Services that require precertification This applies to services performed on an elective, non-emergency basis. Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded. For your reference, we have published a list of medical codes for services that require precertification, which is available on our Medical Policy Portal for commercial and Medicare Advantage members.
External reviewer: Carelon (AIM)
Day rehabilitation programs Elective (non-emergency) ground, air, and sea ambulance transportation
- † Precertification performed by Carelon Medical Benefits Management (formerly AIM Specialty Health), an independent company.
- Precertification review benefit varies based on decision by member's employer group.
External reviewer: eviCore / CareCore
Medical foods Hyperbaric oxygen therapy Proton beam therapy
- * Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company.
- Precertification review benefit varies based on decision by member's employer group.
External reviewer: Tango (PA Medicare lines)
Home-care services
- Precertification review for PA Medicare lines of business is provided by Tango, an independent company.
Precertification: non-specific genetic test procedure codes
ANY genetic test that will be billed with a non-specific procedure code
Precertification vendor and benefit variability
Precertification review vendor and benefit note
- Precertification review for many services and drugs is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company.
- Precertification review benefit varies based on decision by member's employer group; employers may have exclusions or different terms.
Precertification requirement and reviewer
Certain specialty drugs and all listed gene replacement/gene editing therapies, hyaluronate acid products, and other specified pharmaceuticals require precertification.
- eviCore provides precertification review for the listed drugs and therapies.
- Precertification is required for the listed drugs; benefits and any exclusions depend on the member's employer group.
Definitions and Scope Notes
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