CurrentBlue Cross Blue Shield - MainePolicy N/A

Anthem Medicaid Medical Necessity Code List (DX codes)

A listing of diagnosis (DX) codes that Anthem Medicaid designates for medical necessity purposes; intended for providers billing Anthem Medicaid in the covered jurisdiction.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyAnthem Medicaid Medical Necessity Code List (DX codes)

Policy CodePolicy N/A

Change TypeNo material changes indicated

Effective DateN/A

Next Review DateN/A

Key ActionInclude the appropriate listed diagnosis code on claims to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~180DX entries (approx)

Obstetrics/Gynecology-heavyFocus area

HIV & neonatal codesNotable inclusions

Coverage Criteria

Coverage criteria — DX code usage

Covered when the listed diagnosis code applies to the member encounter

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Code Listings and Groups

Hematologic and pulmonary DX codes (partial)ICD-9

042	Human Immunodeficiency Virus [HIV]
277.0x	Cystic Fibrosis
282.xx	Hereditary Hemolytic Anemias
283.xx	Acquired Hemolytic Anemias
284.xx	Aplastic Anemias
285.0	Sideroblastic Anemia
286.0-286.7	Coagulation Defects
287.1	Qualitative Platelet Defects
287.31	Immune Thrombocytopenic Purpura (ITP)
287.32	Evans' syndrome

1–10 of 32

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Gynaecologic/Obstetric DX codes (partial)ICD-9Covered

555.00	Regional enteritis of small intestine
555.10	Regional enteritis of large intestine
555.20	Regional enteritis of small intestine with large intestine
555.90	Regional enteritis of unspecified site
556.90	Unspecified ulcerative colitis
558.10	Gastroenteritis and colitis due to radiation
558.20	Toxic gastroenteritis and colitis
578.90	Hemorrhage of gastrointestinal tract, unspecified
641.00	Placenta previa without hemorrhage, unspecified as to episode of care
641.01	Placenta previa without hemorrhage, with delivery

1–10 of 45

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Additional obstetric and perinatal codes (partial)ICD-9Covered

649.30	Coagulation defects complicating pregnancy, childbirth, or the puerperium
649.31	Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered
649.32	Coagulation defects complicating pregnancy, childbirth, or the puerourium, delivered, with postpartum complic.
649.40	Epilepsy complicating pregnancy, childbirth, or the puerperium
651.00	Twin pregnancy, unspecified as to episode of care
651.01	Twin pregnancy, delivered
655.01	Central nervous system malformation in fetus, with delivery
655.11	Chromosomal abnormality in fetus, affecting management of mother, with delivery
656.11	Rhesus isoimmunization affecting management of mother, delivered
657.00	Polyhydramnios, unspecified as to episode of care

1–10 of 17

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inv-07: Coding — miscellaneous key/value

Inventory noteThis document is a flat listing of diagnosis (DX) codes used by Anthem Medicaid for medical necessity determinations; it provides codes and short descriptions only.

Provider actionInclude the appropriate listed DX code on claims to support medical necessity when Anthem Medicaid requires a listed diagnosis.

Prior authorizationThe code list does not specify services requiring prior authorization; follow Anthem Medicaid prior authorization rules separately.

ExclusionsNo explicit exclusions are provided in this list; it is solely a compilation of diagnosis codes.

Coding systemICD-9 formatted diagnosis codes (numeric codes and V-codes appear)

Provider Actions and Billing Notes

Prior Authorization

Prior Authorization — see payer rules

Prior authorization requirements vary by Blue Cross Blue Shield - Maine plan. Providers must follow payer-specific rules and obtain any required prior authorization before rendering services when applicable.

Check member's plan and BCBS Maine prior authorization policies before scheduling services.
When in doubt, contact the payer's provider services or use the payer portal to verify prior authorization requirements.

Documentation Required

Claim coding/documentation

Include the appropriate diagnosis code from the payer's medical necessity code list on the claim to support medical necessity. This document is a diagnostic code list; ensure the DX code on the claim matches the clinical indication and the codes listed by the payer.

List the primary listed DX code that justifies the service.
Include supporting documentation in the medical record and on request to substantiate medical necessity.

Denial Risk

Potential denial risk from non-listed DX

Claims submitted with diagnosis codes not included on the payer's medical necessity list may be denied if the payer requires a listed DX for coverage. Providers should verify that the member's diagnosis appears on the payer's covered code list before billing.

If the clinical diagnosis is not on the payer's list, obtain prior authorization or submit supporting clinical documentation to avoid denials.
Monitor remittance advices and follow payer appeal procedures if a claim is denied for use of a non-listed diagnosis.

Background

Anthem Medicaid’s Medical Necessity Code List enumerates diagnosis codes in ICD-9 format (numeric codes and V-codes) used to document conditions that may justify medically necessary services. The list is heavily weighted toward obstetrics/gynecology and perinatal conditions but also contains hematologic and pulmonary diagnoses (for example, 042 – Human Immunodeficiency Virus [HIV] and multiple coagulation and anemia codes). Because this file contains codes only, it does not define service-specific clinical criteria; providers must pair the appropriate listed diagnosis code with the service on the claim to support medical necessity and follow any separate prior authorization rules from Anthem Medicaid.

OpenPayer

Anthem Medicaid Medical Necessity Code List (DX codes)

Coverage Criteria

Code Listings and Groups

Provider Actions and Billing Notes

Background

Definitions