Precertification Requirements for Elective (Non‑Emergency) Services
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Lists services, tests, drugs and devices that require precertification for elective (non-emergency) care and clarifies that precertification does not guarantee coverage; applies to AmeriHealth commercial and Medicare Advantage members as indicated. Some reviews are performed by independent review vendors.
No material clinical or coverage changes in this revision.
Precertification-required Services and Test/Agent Lists
Precertification-required services (partial list)
Precertification required for the following elective/non-emergency services; listing is a guide and does not by itself establish coverage.
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
Cardiology procedures
- Arterial ultrasound
- Diagnostic coronary angiography
- Percutaneous coronary intervention
Procedures requiring precertification
- Spine surgeries (various listed)
- Joint arthroplasties and arthroscopy
- Obesity surgery
- Cochlear implant surgery
- Vertebroplasty/kyphoplasty
Reconstructive/cosmetic and related surgeries
- Breast procedures (reconstruction/reduction/augmentation)
- Facial and skin procedures
- Gender-affirming interventions
- Hair transplant
- Injectable dermal fillers
- Varicose vein surgery
Ambulance and day rehab
- Elective ground, air, and sea ambulance
- Day rehabilitation programs
Interventional pain management
- Epidural injections and nerve blocks
- Implanted spinal cord stimulators
- Sacroiliac joint injections
- Facet injections
Advanced imaging and radiology
- CT/CTA
- MRI/MRA
- Nuclear cardiology
- PET
- Echocardiography (TTE/TEE/Stress)
Prosthetics, orthoses, DME
- Custom orthoses and prosthetics
- Bone growth stimulators
- CPAP/BiPAP and supplies
- Power wheelchairs and POVs
- Insulin pumps
- Speech-generating devices
- Pressure-reducing support surfaces
Other therapies and services
- Medical foods
- Hyperbaric oxygen therapy
- Proton beam therapy
Behavioral health and substance use
- Inpatient and intensive levels of mental health care
- Partial hospitalization (PHP), intensive outpatient (IOP), outpatient substance use programs — note: some mandated services may not require precertification
Autism services
- Applied behavioral analysis (precertification review provided by Magellan Healthcare, Inc.)
Genetic and genomic testing
- Hereditary cancer and heart disease panels
- Full gene analysis (e.g., cystic fibrosis)
- Expanded carrier screens
- Specialty oncology tests and tumor profiling
- Listing is a guide; complete procedure code list available on the Medical Policy Portal
Genetic and specialty diagnostic tests requiring precertification
Lists of genetic and specialty tests that are subject to the policy and precertification requirements.
Genetic test categories requiring precertification
- Expanded carrier screening panels (examples: 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 (examples: OncotypeDX, MammaPrint, Afirma, Prosigna, HeproDX)
- Tumor molecular profiling (examples: FoundationOne, neoTYPE, OncoPlexDx and others)
- 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 (examples: Assurex GeneSight, GeneTrait, Genecept, Millennium PGT)
- Warfarin response testing
- MGMT methylation analysis for glioblastoma
Other specialty tests
- Coronary artery disease risk testing (examples: CorusCAD, CardioIQ, APOE, ACE, KIF6)
- Heart disease risk testing (examples: CorusCAD, CardioIQ, APOE, ACE, KIF6, MTHFR)
Genome-wide tests
- Microarray studies
- Whole exome testing
- Whole genome testing
- Mitochondrial genome or nuclear testing
Specialty drugs and biologics requiring precertification (commercial plans)
Specialty drugs and biologics that require precertification for commercial members.
Antineoplastic agents (examples)
- Abraxane, Adcetris, Adstiladrin, Alymsys (except ophthalmological conditions), Anktiva, Avastin (except ophthalmological conditions), Avzivi, Azedra, Blincyto, Columvi, Cyramza, Darzalex, Darzalex Faspro, Enhertu, Erbitux, Herceptin and many others
Anti PD-1/PD-L1 monoclonal antibodies
- Examples include Bavencio, balstilimab, camrelizumab, Imfinzi, Jemperli, Keytruda (including SQ), Libtayo, Loqtorzi, Opdivo (and Opdivo Qvantig), Tecentriq (and Hybreza), and others
Bone-modifying agents
- Examples include Bomyntra, Connexence, Evenity, Jubbonti, Osenvelt, Ospomyv, Prolia, Stoboclo, Wyost, Xgeva, Xbryk
CAR-T therapies
- Examples include Abecma, Aucatzyl, Breyanzi, Carvykti, Kymriah, Tecartus, Yescarta
Enzyme replacement agents
- Examples include Adzynma, Aldurazyme, Brineura, Cerezyme, Elaprase, Elelyso, Fabrazyme, Kanuma, Lumizyme, Mepsevii, Naglazyme, Nexviazyme, VPRIV, Xenpozyme and others
Gene replacement / gene editing therapies
- Examples include Casgevy, Elevidys, Hemgenix, Lenmeldy, Luxturna, Lyfgenia, Roctavian, Skysona, Vyjuvek, Zolgensma, Zynteglo and other listed products
Immunological agents and IVIG/SCIG
- Selected IV/SC immunological agents are listed (examples include Actemra IV, Avsola, Cosentyx IV, Benlysta IV, Entyvio IV, Inflectra, Remicade and others)
Multiple sclerosis and myasthenia gravis agents
- Multiple sclerosis examples include Briumvi, Lemtrada, Ocrevus, Tyruko, Tysabri; Myasthenia gravis examples include nipocalimab, Vyvgart, Rystiggo, Vyvgart Hytrulo
Hyaluronate acid products
- Examples include Cingal, Durolane, Euflexxa, Gel-One, Gelsyn-3, Hyalgan, GenVisc 850, Hymovis, Supartz, Synojoynt, Triluron, TriVisc, VISCO-3
Classes annotated with ** require precertification for any drug that can be classified under that header, including unlisted brand/generic names and newly FDA-approved drugs/biosimilars during the benefit year.
Agent inventory (partial)
Agent lists by category (partial inventory). These lists enumerate agents subject to precertification; no eligibility or utilization criteria are provided in this section.
Multiple sclerosis agents**
- Briumvi
- Lemtrada
- Ocrevus
- Tyruko
- Tysabri
Myasthenia gravis agents**
- nipocalimab
- Vyvgart
- Rystiggo
- Vyvgart Hytrulo
Neutropenia agents
- Fulphila
- Fylnetra
- Granix
- Grastofil
- Lapelga
- Neupogen
- Nypozi
- Releuko
- Rolvedon
- Stimufend
- Ryzneuta
- Udenyca and Udenyca OnBody
- Ziextenzo
Ophthalmic agents
- Ahzantive
- Beovu
- bevacizumab-vikg
- Byooviz
- Cimerli
- Enzeevu
- Eylea (including Eylea HD)
- Lucentis
- Susvimo
- Tepezza
- Vabysmo
Pulmonary arterial hypertension agents**
- Flolan
- Remodulin
- Tyvaso
- Revatio
- Uptravi IV
- Ventavis
- Veletri
Respiratory agents
- Cinqair
- Omlyclo
- Synagis
- Xolair
Respiratory enzymes (alpha-1 antitrypsin)**
- Aralast
- Glassia
- Prolastin
- Zemaira
TIL and T-cell therapies**
- Amtagvi
- Imdelltra
- linvoseltamab
- Tecelra
Miscellaneous therapeutic agents
- Adakveo
- Amvuttra
- Crysvita
- Enjaymo
- Leqvio
- Onpattro
- Soliris
- Spinraza
- Ultomiris IV
Coding and Billing Codes Requiring Review
Precertification Process, External Review Vendors, and Drug-class Rules
Precertification requirement and limitation
Precertification is required for the listed elective/non-emergency services; precertification does not guarantee coverage and the member's benefit plan terms and exclusions determine coverage.
External review vendor — Carelon/AIM
Precertification review for certain services (for example, day rehabilitation programs and elective ambulance transportation) is performed by Carelon Medical Benefits Management (formerly AIM Specialty Health). The benefit for these Carelon-performed reviews varies based on the member's employer group decision.
- Carelon performs precertification reviews for specified services.
- Precertification review benefit varies by employer group.
External review vendor — eviCore
Precertification review for proton beam therapy and hyperbaric oxygen therapy is provided by CareCore National, LLC d/b/a eviCore healthcare; the availability of this review and benefit varies based on the member's employer group.
- eviCore provides precertification review for proton beam and hyperbaric oxygen therapy.
- Precertification review benefit varies by employer group.
External review vendor — Magellan
Precertification review for applied behavioral analysis (autism spectrum disorder services) is provided by Magellan Healthcare, Inc., an independent company.
- Magellan performs precertification reviews for applied behavioral analysis.
- Coverage issued by AmeriHealth entities as noted in the policy.
Precertification for non-specific/unlisted genetic test codes (81400-81408, 81479, 81599, 84999)
Any genetic test billed with non-specific CPT codes 81400–81408 or with unlisted codes 81479, 81599, or 84999 requires precertification review; precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare and the review benefit may vary by the member's employer group.
Specialty drug precertification requirement
All specialty drugs listed (and their generic equivalents or biosimilars) require precertification for members enrolled in commercial plans; the specialty drug list is subject to change and Medicare Advantage requirements are published separately.
- All listed brands and their generic equivalents or biosimilars require precertification for commercial plan members.
- List is subject to change; Medicare Advantage precertification information is on the Medicare Advantage website.
Multiple sclerosis agents — precertification required
Multiple sclerosis agents (classified with **) require precertification. Examples listed include Briumvi, Lemtrada, Ocrevus, Tyruko, and Tysabri.
- Briumvi
- Lemtrada
- Ocrevus
- Tyruko
- Tysabri
Myasthenia gravis agents — precertification required
Myasthenia gravis agents (classified with **) require precertification. Examples listed include nipocalimab, Vyvgart, Rystiggo, and Vyvgart Hytrulo.
- nipocalimab
- Vyvgart
- Rystiggo
- Vyvgart Hytrulo
Neutropenia agents — precertification required
Neutropenia agents require precertification; listed products include Fulphila, Fylnetra, Granix, Grastofil, Lapelga, Neupogen, Nypozi, Releuko, Rolvedon, Stimufend, Ryzneuta, Udenyca (including OnBody), and Ziextenzo.
- Fulphila
- Fylnetra
- Granix
- Grastofil
- Lapelga
- Neupogen
- Nypozi
- Releuko
- Rolvedon
- Stimufend
- Ryzneuta
- Udenyca (including OnBody)
- Ziextenzo
Ophthalmic agents — precertification required
Ophthalmic agents listed require precertification; examples include Ahzantive, Beovu, bevacizumab-vikg (and other biosimilars), Byooviz, Cimerli, Eylea (including Eylea HD), Lucentis, Susvimo, Vabysmo, and others.
- Ahzantive
- Beovu
- bevacizumab-vikg (biosimilar)
- Byooviz
- Cimerli
- Eylea (including HD)
- Lucentis
- Susvimo
- Vabysmo
Pulmonary arterial hypertension agents — precertification required
Pulmonary arterial hypertension agents (classified with **) require precertification. Listed examples include Flolan, Remodulin, Tyvaso, Revatio, Uptravi IV, Ventavis, and Veletri.
- Flolan
- Remodulin
- Tyvaso
- Revatio
- Uptravi IV
- Ventavis
- Veletri
Respiratory agents — precertification required
Respiratory agents listed require precertification; examples include Cinqair, Omlyclo, Synagis, and Xolair.
- Cinqair
- Omlyclo
- Synagis
- Xolair
Respiratory enzymes (alpha-1 antitrypsin) — precertification required
Respiratory enzyme (alpha-1 antitrypsin) products (classified with **) require precertification. Listed products include Aralast, Glassia, Prolastin, and Zemaira.
- Aralast
- Glassia
- Prolastin
- Zemaira
TIL and T‑cell therapies — precertification required
Tumor-infiltrating lymphocyte (TIL) and T‑cell therapies require precertification. Examples listed include Amtagvi, Imdelltra, linvoseltamab, and Tecelra.
- Amtagvi
- Imdelltra
- linvoseltamab
- Tecelra
Miscellaneous therapeutic agents — precertification required
Miscellaneous therapeutic agents listed require precertification; examples include Adakveo, Amvuttra, Crysvita, Enjaymo, Leqvio, Onpattro, Soliris, Spinraza, Ultomiris IV, and many others.
- Adakveo
- Amvuttra
- Crysvita
- Enjaymo
- Leqvio
- Onpattro
- Soliris
- Spinraza
- Ultomiris IV
Key Definitions and Notes
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