CurrentFidelis CarePolicy N/A

Authorization requirements for services and procedures

Governs prior authorization requirements for Fidelis Care members in New York for inpatient, outpatient, behavioral health, DME, imaging, therapy, pharmacy/infusion, and selected procedures.

Policy Summary

PayerFidelis Care

PolicyAuthorization requirements for services and procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for listed services and procedures before billing; submit pharmacy/infusion and enteral requests via e-fax to the Fidelis Pharmacy Team at 1-877-533-2405.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All require authInpatient admissions

60Therapy visit limit

4OB ultrasound threshold

40Home health max

210Hospice max (days)

1-877-533-2405

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Pharmacy prior auth fax

Services Requiring Prior Authorization and Coverage Rules

Inpatient Admissions

Covered when ALL of the following are met

Inpatient admission: All inpatient admissions require authorization and are reviewed for medical necessity.

Fidelis Care does not require authorization of emergency room services or emergent stabilization; post-stabilization inpatient admissions require authorization.

Transplants

Transplant authorization: All solid organ and bone marrow transplants require authorization at the time of the transplant evaluation.

Includes the listed CPT ranges (e.g., 32850-32856, 33930-33945, 38204-38215, 38230-38242, 44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757).

Outpatient PT/OT/ST

Outpatient therapy authorization: Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services performed after the initial evaluation require prior authorization for services rendered on or after 10/1/2019; initial evaluations do not require authorization but other billed procedure codes, even if performed on the same date as the initial evaluation, require authorization prior to billing.

Authorization for these outpatient therapy services is delegated to National Imaging Associates (NIA) for authorization processing.

Durable Medical Equipment/Supplies

DME authorization: Certain durable medical equipment (DME) and supply items require prior authorization; a list of DME codes that do not require authorization is provided and orthotics are not covered.

Specific items requiring authorization include compression garments/stockings, electric breast pumps, surgical stockings, wigs, protective helmets, insulin pumps, insulin infusion pumps, electric heating pads; some items are covered through the prescription drug benefit. Home health and hospice limits are noted separately.

OASAS Inpatient Substance Use Disorder Treatment

OASAS inpatient SUD notification: The initial 14 days of OASAS-licensed inpatient detoxification, inpatient rehabilitation, or inpatient residential SUD treatment do not require prior authorization but providers must notify Fidelis Care of each admission within 48 hours by faxing or emailing the OASAS Appendix A Notification Form and the OASAS LOCADTR Medical Necessity Tool.14 days

Services during the initial 14 days are subject to periodic consultation and may be subject to utilization review after day 14 or upon discharge; out-of-state and out-of-network providers must request authorization for inpatient SUD treatment.

Rehabilitation and Habilitation Authorization and Limits

Coverage and authorization conditions for therapy services

Therapy authorization and limits: Services rendered on or after 10/1/2019 require prior authorization (except PT/OT/ST initial evaluations). Rehabilitation and habilitation benefits are each limited to 60 visits per condition per plan year; the combined visit limit applies to all therapies.60 visits per condition per plan year

Initial evaluations are exempt from prior authorization but other billed procedure codes on the same date require prior authorization before billing.

Podiatry Authorization and Coverage

Podiatry services: Podiatric services rendered to members with a confirmed diagnosis of Diabetes Mellitus do not require authorization; the diabetes diagnosis must be included on the claim. Podiatric services for members without diabetes continue to require authorization, and routine foot care for non-diabetics is not covered.

Podiatrists must obtain authorization for all DME codes supplied in the office regardless of member diagnosis.

Low Back Pain - Not Covered Therapeutic Services

Not covered for members with a diagnosis of Low Back Pain

Not covered interventions for low back pain: Prolotherapy; therapeutic injections of steroids into intervertebral discs; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); continuous or intermittent traction; and the listed pain management injection codes are not covered for members with a diagnosis of low back pain.

These services and listed pain management codes are identified as not covered when the member's diagnosis is low back pain.

Enteral and Specialty Pharmacy Authorization

Enteral and specialty drugs: Enteral therapy HCPCS codes B4034-B4162 and numerous J-, C-, and G-codes listed require prior authorization; prior authorization requests for the listed specialty pharmacy/infusion codes must be submitted to the Fidelis Care Pharmacy Team electronically via e-fax to 1-877-533-2405.

Exception: B4088 (B4O88) is listed as not requiring authorization.

Many elective surgical and medical procedures that are completed within 24 hours will not be approved at an inpatient level of care. When these procedures are performed as outpatient services within the Fidelis Care network they do not require authorization. Examples include, but are not limited to, laparoscopic procedures and thyroid surgery completed within 24 hours of the onset of surgery.

Routine foot care for members without diabetes is not covered. For podiatric services rendered to members with a confirmed diagnosis of Diabetes Mellitus, authorization is not required, but the diabetes diagnosis must be included on the claim when services are billed. Podiatrists must continue to obtain authorization for any DME codes supplied in the office regardless of member diagnosis.

Routine foot care for non‑diabetic members is explicitly excluded from coverage. This exclusion is reiterated in the policy to emphasize that routine podiatric foot care for non‑diabetics is not a covered benefit.

Certain therapeutic services and injections are not covered for members with a diagnosis of Low Back Pain. Non‑covered interventions include prolotherapy, therapeutic injections of steroids into intervertebral discs, therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance), and continuous or intermittent traction. The policy lists additional pain management injection codes and related supplies that are not covered for this diagnosis.

Authorization is not required for the listed J/HCPCS codes when they are used for oncology indications. Prior authorization requests for the specialty pharmacy/infusion codes otherwise listed in this section should be submitted to the Fidelis Care Pharmacy Team via electronic fax to 1-877-533-2405.

CPT code 96110 is identified in this policy as a non‑covered service and therefore does not require (and will not be approved with) prior authorization.

Examples of therapeutic injections and procedures that are not covered for members with a diagnosis of Low Back Pain include therapeutic injections listed in the pain management section (e.g., codes such as 20526, 20550-20553, 21073, 27096, and spinal/epidural injection codes 62263-62264, 62273, 62280-62282, 62290, 62310-62311, 62318-62320). The policy also references related supply codes (for example C1823, C9752, C9753) where applicable and notes that these services are not covered when billed for low back pain.

Relevant CPT / HCPCS / Revenue Codes

Transplant-related CPT rangesCPTCovered

32850-32856
33930-33945
38204-38215
38230-38242
44133-44136
47133-47147
48160
48550-48556
50300-50380
50547

1–10 of 11

1/2

Selected surgical and dermatologic CPT codes requiring authorization in certain settingsCPTCovered

43770-43775	Bariatric surgery
S2083	Bariatric related
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction range
19300	Breast procedures
19316-19342	Breast reconstruction additional
19355
19370-19396
10040	Skin surgery (example)
11300-11313	Skin surgery

1–10 of 28

1/3

Vascular, ENT, gender reassignment, spinal and other proceduresCPTCovered

36465-36466	Vein procedures
36468-36479
36482-36483
37718-37785
37241-37244
31295-31297
55970	Gender reassignment surgery
55980
20932-20934
22867-22870	Spinal surgery codes

1–10 of 12

1/2

Developmental/psych testingCPTCovered

96110	Non-covered service
96112
96113
96116
96121
96130-96139	Psychological/Neuropsychological testing series
96146

Behavioral health / ASD related HCPCS/CPT codesmixedCovered

H0035
H2013
S9480
90899

Residential treatment codesmixedCovered

1001	Residential treatment
1002	Residential treatment
H0017-H0019
H2036

Diagnostic and GI procedure codesCPTCovered

91110	Wireless capsule endoscopy
91111
43235	GI procedure
43239
43248
45378
45380
45384
45385
46255

1–10 of 12

1/2

DME codes that do not require authorization (listed) and others that may require authorizationCPT/HCPCS

E0130
E0135
E0168
E0182
E0184
F0235
F0274
E0305
E0310
E0424

1–10 of 48

1/5

Therapy services (PT/OT/ST) operational notesmixed

No codes listed

Delegated vendormixed

eviCore

Delegated radiology vendor for authorization

Therapy evaluation exceptionsmixed

PT/OT/ST initial evals

Initial evaluations for PT, OT, and ST do not require authorization

Therapeutic services requiring authorizationCPT | HCPCSCovered

99183	Hyperbaric oxygen therapy
C1300	Hyperbaric oxygen (HCPCS)
95249	Ambulatory continuous glucose monitoring

ChiropracticCPT | RevenueCovered

98940-98943	Chiropractic manipulation codes
0940	Revenue code associated with chiropractic

Telehealth codesHCPCSCovered

G2010	Remote evaluation of recorded video and/or images
G2012	Brief communication technology-based service

Pain management codes (examples listed)CPT | HCPCSCovered

20526	Therapeutic injection; trigger point (myofascial pain)
20550-20553	Therapeutic injection codes
21073	Injection (code listed in pain management codes)
27096	Injection into sacroiliac joint
62263-62264	Injection/infusion procedures (spinal)
62273	Epidural injection
62280-62282	Spinal injection with imaging
62290	Spinal injection code
62310-62311	Epidural steroid injection
62318-62320	Spinal injection codes

1–10 of 13

1/2

Cardiac and pulmonary rehabilitationHCPCS | RevenueCovered

G0237-60239	Pulmonary rehab (range notation in source)
G0424	Pulmonary rehabilitation program
S9473	Pulmonary rehab service
0943	Revenue code for rehab services

Enteral and specialty pharmacy/infusion codesHCPCS | J-codes | B-codesCovered

B4034-B4162	Enteral formulas and disposable enteral items (require authorization)
C9054	Multiple associated J-codes listed (see document) - requires authorization
C9055	Multiple associated J-codes listed (see document) - requires authorization
G0516-G0518	Implant insertion/removal codes with associated J-codes
J0129-J2507	Extensive list of J-codes for biologics/infusions that require authorization (document lists many specific mappings and agents)
J2787	Riboflavin ophthalmic (Photrexa) - listed among codes requiring authorization

Podiatry exclusionsmixedNot Covered

routine foot care

Routine foot care for non-diabetics is not covered

Codes requiring prior authorizationHCPCSCovered

J2170	various biologics (entries list specific biologic mappings)
J2182	various biologics
J2323	various biologic drug
J2326	nusinersen (Spinraza) and related
J2350	ocrelizumab (Ocrevus) and related
J2353	octreotide depot (Sandostatin) and related
J2354	octreotide non-depot and related
J2357	omalizumab (Xolair) and related
J2440	papaverin and related
J2503	pegaptanib (Macugen) and related

1–10 of 46

1/5

OB ultrasound count — Authorization threshold

ThresholdFirst 4 OB ultrasounds for a normal pregnancy do not require authorization; 5 or more ultrasounds for a normal pregnancy require authorization

Applies toOB ultrasounds for a normal pregnancy (diagnosis codes referenced in source)

Authorization routeRadiology services require authorization through eviCore Healthcare (see radiology vendor)

What Providers Must Do (Submissions, Notifications, and Risks)

Prior Authorization

General prior authorization requirement — Authorization required for services and procedures listed

FIDELIS CARE AUTHORIZATION REQUIREMENTS: Many services and procedures require prior authorization. There are no out-of-network benefits; however, authorization will be provided when a medically necessary service is not available in-network.

Out-of-Network: No OON benefits; authorization provided only when medically necessary service is unavailable in-network.

Prior Authorization

Transplant authorization — All solid organ and bone marrow transplants require authorization at time of transplant evaluation

All solid organ and bone marrow transplants require authorization at the time of the transplant evaluation.

Includes but not limited to codes: 32850-32856, 33930-33945, 38204-38215, 38230-38242, 44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757.

Policy Scope and Purpose

This document defines administrative prior authorization requirements for a range of services and procedures. Providers must obtain authorization for services listed in the policy prior to rendering care where required; all inpatient admissions require authorization and failure to obtain authorization for inpatient admissions or post‑stabilization inpatient services may result in claim denial. Emergency department services rendered for initial stabilization do not require prior authorization, but subsequent inpatient care does require authorization and review for medical necessity.

Key Terms and Limits

OASAS licensed inpatient services — definition/coverage

DefinitionInpatient detoxification, inpatient rehabilitation, or inpatient residential substance use disorder treatment under New York State Office of Addiction Services and Supports (OASAS)

Initial authorizationFidelis Care will not conduct authorization review for the initial 14 days of OASAS licensed inpatient SUD treatment

Provider notificationProviders must notify Fidelis Care within 48 hours by faxing or emailing the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool

Visit limit — combined therapy cap

Combined capA combined cap of 60 therapy visits per condition per plan year applies to rehabilitation and habilitation services

Therapy types included

Policy Summary

PayerFidelis Care

PolicyAuthorization requirements for services and procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for listed services and procedures before billing; submit pharmacy/infusion and enteral requests via e-fax to the Fidelis Pharmacy Team at 1-877-533-2405.

SourceLink

On This Page

Therapy visit limit

Visit cap60 visits per condition per plan year (rehabilitation and habilitation combined)

Effective date for therapy prior authServices rendered on or after 10/1/2019 require prior authorization (initial evaluations exempt)

Applies toPhysical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST)

Rehabilitation/habilitation visit cap

Rehabilitation/habilitation limit60 visits per condition per plan year (visit limit applies to all therapies combined)

ScopeSeparate benefit categories: Rehabilitation and Habilitation each limited to 60 visits per condition per plan year

Authorization noteAll billed procedure codes after the initial evaluation require prior authorization directly through Fidelis Care

Counseling services allowance

AllowanceMembers are allowed 10 hours (20 units) in a continuous 12‑month period for counseling services

AuthorizationThese counseling services no longer require authorization when provided by certified providers

Billing codesServices are covered when billed with codes G0108 and G0109

Prior Authorization

Developmental testing authorization — Testing codes require authorization using specified testing request process

Authorization is required for specified developmental pediatric testing. Submit requests using the designated testing request process/form.

Psychological/Neuropsychological Testing codes requiring authorization: 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146.
Authorization required for 96112 and 96113. Note: 96110 is non-covered.
All requests should be submitted on the Psychological/Neuropsychological testing request form.

Prior Authorization

Diagnostic testing authorization — Specific diagnostic testing and wireless capsule endoscopy codes require authorization; certain GI procedures require authorization when indicated

Specific diagnostic tests and certain GI procedures require prior authorization. Some genetic tests are excepted and have lifetime limits.

Breast cancer genetic testing: Authorization required except CPT 81220, 81329, 81336 (these three do not require authorization). CPT 81220 limit: 1 per lifetime. CPTs 81329 and 81336 combined limit: 1 per lifetime.
Wireless Capsule Endoscopy: 91110, 91111 require authorization.
Gastroenterology procedures (when performed in POS 19 or 22 and an office-based/ASC alternative exists) requiring authorization: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270. These do NOT require authorization when performed in POS 11 or 24.

Prior Authorization

DME authorization — Many DME and supply items require authorization; lists identify items that do not require authorization

Durable medical equipment and many supplies require prior authorization. The policy identifies items that do not require authorization and items/supplies that do require authorization.

Examples of DME codes that do NOT require authorization: E0130, E0135, E0168, E0182, E0184, F0235, F0274, E0305, E0310, E0424, E0431, E0434, E0570, E0575, E0580, E0621, E0655, E0660, E0776, E0890, E0900, E0942, E2361, E2363, L0130, L0140, L0160, L0170, L0172, L0174, L080, L0190, L1652, L1902, L2132, L2134, L2136, L3100, L3221, L3762, L7360, L7362, L7364, L7366, S8421, S8424, V5266.
Supplies that require authorization include compression garments/gradient stockings, electric heat/water pads, electric breast pumps, surgical stockings, wigs, protective helmets, insulin pumps and insulin infusion pumps.
Orthotics are not covered.
Home health care approvals and hospice care have specified limits and require authorization when medically necessary.

Prior Authorization

Outpatient therapy authorization — Outpatient PT/OT/ST (after initial evaluation) require authorization for services rendered on/after 10/1/2019 through delegate

Outpatient PT/OT/ST services rendered after the initial evaluation require prior authorization. Initial evaluations do not require authorization, but all subsequent billed procedure codes (even if on same date as evaluation) require authorization.

Effective 10/1/2019, outpatient therapy (PT, OT, ST) services after the initial evaluation require authorization.
Initial therapy evaluations do not require authorization.
All other billed procedure codes after the initial evaluation require prior authorization prior to billing.
Benefit limits: Rehabilitation and Habilitation are limited to 60 visits per condition per plan year (combined across therapies).

Denial Risk

Prior authorization for post-evaluation therapy services — All billed procedure codes (except initial evaluations) after initial evaluation date require prior authorization

All billed procedure codes for therapy services after the initial evaluation date require prior authorization (except the initial evaluation). Failure to obtain authorization may result in claim denial.

PT/OT/ST initial evaluations do not require authorization.
Any other therapy codes billed after the initial evaluation require prior authorization prior to billing.

Prior Authorization

Therapeutic services prior authorization — Specific therapeutic services (examples listed) require authorization

Certain therapeutic, cardiac/pulmonary rehab, chiropractic, and other procedure codes require authorization. Cardiac and pulmonary rehab delivered outpatient require authorization.

Cardiac and pulmonary rehabilitation require authorization for outpatient services. Pulmonary rehab codes include G0237-60239, G0424, S9473, revenue code 0943.
Chiropractic codes requiring authorization: 98940-98943 and revenue code 0940.
Other therapeutic services (e.g., hyperbaric oxygen 99183, C1300) and listed pain management codes require authorization or are not covered per policy.

Billing Rule

Diabetes diagnosis on podiatry claims — Include diabetes diagnosis on podiatry claims for diabetic members

Podiatry services for members with a confirmed diagnosis of Diabetes Mellitus do NOT require authorization. When billing podiatry services for diabetic members, include the diabetes diagnosis on the claim. Podiatric services for members without diabetes continue to require authorization. Office-supplied DME by podiatrists requires authorization regardless of diagnosis. Routine foot care for non-diabetics is not covered.

Include diabetes diagnosis on podiatry claims for diabetic members.
Podiatric DME supplied in-office requires authorization regardless of member diagnosis.

Documentation Required

Enteral formula written order — Non-prescription enteral formulas for home use require written order stating medical necessity

Enteral formulas and related disposable enteral items (HCPCS B4034-B4162) require authorization. Non-prescription enteral formulas for home use require a written order from a physician or licensed provider stating medical necessity and documenting that the formula is a disease-specific, medically necessary treatment to prevent malnutrition or serious disability.

Enteral HCPCS codes B4034-B4162 require authorization (B4088 is an exception).
Written order must state medical necessity and that the formula is proven effective as a disease-specific treatment for conditions such as inherited metabolic disorders, Crohn's disease, severe food allergies, chronic intestinal pseudo-obstruction, gastroesophageal reflux with failure to thrive, and similar conditions.

Prior Authorization

Codes requiring authorization — Listed J- and related HCPCS codes require prior authorization; submission to Fidelis Pharmacy Team noted

Numerous J- and related HCPCS codes require authorization. Prior authorization requests for these pharmacy/infusion and enteral codes must be submitted to the Fidelis Pharmacy Team electronically via e-fax.

These specialty J-/HCPCS codes require authorization (many examples listed in the formulary section); authorization submission route: e-fax to Pharmacy Team at 1-877-533-2405.
Authorization is not required for oncology indications for certain listed codes (see oncology exception in formulary guidance).
Failure to obtain authorization for these J/HCPCS codes may result in claim denial.

Applies to PT, OT, and ST with visits counted across therapy types

Authorization timingServices rendered on or after 10/1/2019 require prior authorization (initial evaluations do not require authorization)

Enteral therapies (B4034-B4162) — codes requiring authorization

HCPCS rangeEnteral therapy codes B4034-B4162 describe enteral formulas and disposable enteral items that require authorization

Use caseIncludes enteral formulas and disposable items for home use that require authorization

Order requirementNon‑prescription enteral formulas for home use require a written order stating medical necessity and disease‑specific effectiveness

Examples of indicationsIncludes inherited metabolic disorders, Crohn's disease, gastroesophageal reflux with failure to thrive, chronic intestinal pseudo‑obstruction, severe food allergies