Fidelis Care Prior Auth & Utilization Policy Update | OpenPayer
CurrentFidelis CarePolicy N/A
Prior Authorization and Utilization Management Requirements for Inpatient, Outpatient, Behavioral Health, and Related Services
This document describes Fidelis Care requirements for prior authorization, concurrent review, and utilization management for a wide set of inpatient, outpatient surgical, transplant, behavioral health, substance use disorder, and related services for members (primarily New York State). It affects providers submitting authorization requests and facilities providing these services.
Policy Summary
PayerFidelis Care
PolicyPrior Authorization and Utilization Management Requirements for Inpatient, Outpatient, Behavioral Health, and Related Services
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for all inpatient admissions (post‑stabilization) and for listed outpatient, transplant, behavioral health, DME and procedural services as specified.
No material clinical or coverage changes in this revision.
28 daysOASAS SUD exemption
14 daysOMH under-18 exemption
Day 31Concurrent review trigger
All inpatientRequire authorization
Multiple lists
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Outpatient procedures
V26.0-06/01/2026Appendix version
Coverage Criteria and Medical Necessity
Inpatient admissions
Covered when ALL of the following are met
Inpatient admissions require authorization: All inpatient admissions require prior authorization (emergency services and initial stabilization excluded); Fidelis Care requires authorization of post-stabilization inpatient admissions and all acute inpatient facility services, including inpatient rehabilitation (acute, sub-acute and skilled nursing rehabilitation). All facility admissions are reviewed for medical necessity.
Providers must obtain authorization for inpatient admissions after emergency department stabilization; new fax number for Inpatient ER notifications provided in policy.
Inpatient SUD (OASAS) rules
Special rules for Inpatient Substance Use Disorder (SUD)
In-network NY OASAS-licensed facilities: Inpatient SUD services provided by New York State facilities that are licensed/certified/authorized by OASAS and participating in Fidelis Care's provider network are not subject to prior authorization review and are exempt from concurrent utilization review for the first twenty-eight (28) days of the inpatient admission, provided the facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days and submits the OASAS Appendix A Notification Form and LOCADTR tool information.28 days
After day 28 services may be subject to utilization review; facilities outside NY, not OASAS-licensed, or out-of-network must request prior authorization and are subject to concurrent review throughout the admission.
OMH inpatient mental health criteria
Special rules for OMH-licensed inpatient mental health treatment
Triggers for utilization review in OMH settings: Utilization review (prior authorization and concurrent review) for OMH-licensed inpatient mental health treatment will be conducted only for members who meet specified clinical criteria per the NYS OMH Best Practice Manual: current Assisted Outpatient Treatment (AOT) court order; AOT expired within five years; high utilization as defined (three or more psychiatric inpatient hospitalizations in prior 12 months OR four or more psychiatric ED visits in prior 12 months OR three or more medical inpatient hospitalizations in prior 12 months); readmission within 30 days of discharge; or length of stay exceeding 30 days (concurrent review from Day 31 onward).see node text
Members under age 18 in-network are exempt from prior authorization and concurrent review for the first 14 days if the facility notifies Fidelis Care within two business days using the OMH 'Two-Day Notification and Initial Treatment Plan' form, performs daily clinical review, and participates in periodic consultation with Fidelis Care.
Selected outpatient procedures require prior authorization: Specific lists and ranges of CPT, HCPCS and Q-codes require prior authorization when performed in certain settings or at any place of service as indicated (including bariatric surgery codes 43770/43772/43773/43774; blepharoplasty 15820-15823; breast reconstruction ranges; numerous dermatologic, vascular, spinal, ENT, cardiac, CAR-T, urology, hernia, and other procedure codes listed in the policy and appendices).
Some codes/delegations are directed to TurningPoint or Evolent (NIA) per the coding sections; authorization and place-of-service rules vary by code (see coding module and Appendix I for full lists).
Behavioral Health coverage criteria
Behavioral health outpatient/partial/intensive/ASD/Residential rules
Psychological/Neuropsychological Testing and Developmental Testing: Authorization is required for listed CPT codes for psychological and neuropsychological testing (96116, 96121, 96130-96133, 96136-96139, 96146) and for developmental pediatric testing (96112, 96113); CPT 96110 is listed as a non-covered service for developmental testing. Requests should be submitted using the Psychological/Neuropsychological testing request form.
Partial Hospitalization and Intensive Outpatient (OMH licensed) utilization review triggers: Utilization review for partial hospitalization and intensive outpatient mental health treatment in OMH-licensed programs will be conducted only for members meeting the NYS OMH Best Practice Manual clinical criteria (AOT status, high utilization, readmission, or length of stay >30 days).
Out-of-network facilities remain subject to concurrent review throughout the admission.
Autism Spectrum Disorder related services: Authorization is required for DME speech generation equipment and for Applied Behavior Analysis (ABA); attestation of ASD diagnosis must be provided at the time of request by a licensed physician or psychologist. State-expanded benefits include increased case management, certain DME to assist speech performance, and ABA.
TMS Coverage Criteria
TMS coverage when ALL of the following are met
TMS coverage criteria: Member age >18; TMS administered using an FDA-cleared device in accordance with FDA-labeled indications; confirmed diagnosis of major depressive disorder (MDD); failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode of illness.
Authorization is required for CPT codes 90867, 90868, and 90869; requests may be submitted via email, fax, or phone following Behavioral Health prompts.
Autism Spectrum Disorder (ASD) Requirements
ASD-related services requiring authorization or attestation
ASD requirements: Attestation of an Autism Spectrum Disorder diagnosis by a licensed physician or psychologist must be provided at the time of request; authorization is required for DME speech generation equipment; Applied Behavior Analysis requires Behavioral Health authorization.
State-expanded ASD benefits described in policy include increased case management, certain DME, and ABA.
Outpatient and Home Therapy Coverage Criteria
Therapy authorizations and visit limits
Outpatient Therapy Authorization: Effective 10/1/2021, outpatient and home physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services after the initial evaluation require prior authorization through Evolent (initial office/facility evaluation does not require authorization but subsequent billed procedure codes do). CPT codes 92610 and 92611 do not require prior authorization.Rehabilitation: 60 visits per condition per plan year; Habilitation: 60 visits per condition per plan year
For home settings different submission timeframes apply (see policy): authorization requests to Evolent within 2 business days for home health settings; inpatient therapy authorizations to Fidelis within 1 business day.
DME Coverage and Authorization
DME and supplies
DME authorization: A specified list of DME HCPCS codes do not require authorization (see policy list). Other DME codes require authorization. Specific supplies requiring authorization include compression garments/stockings, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps and insulin infusion pumps. Codes for blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered under the prescription drug benefit. T2101 (Donor Breast Milk) requires authorization only when provided in an outpatient setting.
Home health benefit maximum visits per plan year is 40; hospice coverage up to 210 days when medically necessary.
Imaging Coverage Criteria
Imaging prior authorization rules
OB ultrasound rules: First four OB ultrasounds for a normal pregnancy may be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization. OB ultrasounds for high-risk pregnancy do not require authorization.4 ultrasounds without authorization
A full list of CPT codes requiring prior authorization and delegations (Evolent NIA, TurningPoint for cardiac ultrasounds) is provided in the policy and coding modules.
Radiology delegation: Prior authorization for radiology services has been delegated to Evolent (NIA); many non-OB ultrasounds may not require prior authorization but specific CPT lists should be consulted.
Cardiac ultrasounds delegated to TurningPoint per policy.
Pharmacy/Oncology Prior Authorization
Pharmacy/Oncology coverage routing and exclusions
Oncology medications and supportive agents require prior authorization from Evolent before being dispensed at a pharmacy or administered in outpatient/physician office/ambulatory settings; requests are submitted via Evolent's web portal or phone per the policy. Appendix I lists additional HCPCS/J/C and other codes that require prior authorization and are to be submitted to the Pharmacy Team via e-fax for Appendix I items.
Certain request types are excluded from Evolent review (e.g., antibiotics, bone marrow/stem cell transplants, CAR-T, Cablivi, controlled substances, equipment requests, genetic testing, hemophilia drugs, immune globulins, inpatient drug requests, iron preparations, pain medications, radiopharmaceuticals, surgeries/procedures, sickle cell diagnoses); see policy exclusions.
CPT code 20610 (arthrocentesis/arthroscopic procedure) is expressly designated non-covered when billed in combination with specified intra‑articular hyaluronic acid products (e.g., J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332) for members with a diagnosis of osteoarthritis of the knee (diagnosis codes in the M17 series, including M17.0, M17.1, M17.10, M17.11, M17.12, M17.2, M17.3, M17.30, M17.31, M17.32, M17.4, M17.5, M17.9). In all other situations CPT 20610 does not require authorization.
CPT 96110 (developmental pediatric testing) is listed as a non-covered service. Authorization is required for related developmental and psychological testing codes (for example, 96112 and 96113 require authorization) and other listed psychological/neuropsychological testing codes must be submitted on the specified request form.
Certain categories of pharmacy requests are excluded from routing to Evolent for review. Examples include: antibiotics; bone marrow/stem cell transplants and CAR‑T cell therapy; Cablivi; controlled substances; equipment requests; genetic laboratory testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; and items related to sickle cell diagnoses. Self‑administered medications remain covered under the pharmacy benefit and certain oncology routing exceptions are described in the pharmacy section.
Most S‑codes are treated as benefit exclusions. The policy identifies S0013, S0189, S0190, S0191, and S9435 as exceptions to that exclusion list. For oral medications billed with S‑codes, the policy directs use of the member’s prescription benefit rather than medical benefit authorization channels.
HCPCS codes that represent medications which are not FDA‑approved are considered a benefit exclusion. The policy cites J1726 as an example of this category and states these codes should not be processed through the medical prior authorization pathway.
When CPT 20610 is billed together with the specified hyaluronic acid J‑codes and an osteoarthritis of knee diagnosis from the M17 series, the combination is explicitly designated non‑covered. Outside of that specific combination, 20610 does not require prior authorization.
For members with a diagnosis of Low Back Pain, the policy lists certain services as not covered: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); therapeutic steroid injections into intervertebral discs; and continuous or intermittent traction. Authorization is required for other specified therapeutic services (for example, cardiac and pulmonary rehabilitation) where indicated in the therapeutic services section.
Code Lists and Authorization-by-Code
Transplant-related CPT codesCPTCovered
32850
listed transplant-related code
32851
listed transplant-related code
32852
listed transplant-related code
32853
listed transplant-related code
32854
listed transplant-related code
32855
listed transplant-related code
32856
listed transplant-related code
33930
listed transplant-related code
33931
listed transplant-related code
33932
listed transplant-related code
1–10 of 74
1/8
Outpatient surgery and dermatologic codes requiring prior authorization (selected)mixedCovered
43770
Bariatric surgery
43772
Bariatric surgery
43773
Bariatric surgery
43774
Bariatric surgery
15820
Blepharoplasty
15821
Blepharoplasty
15822
Blepharoplasty
15823
Blepharoplasty
11920-11971
Breast reconstruction/mammoplasty range
19300
Breast reconstruction
1–10 of 24
1/3
Orthopedic/arthrocentesis specific coverage rulesmixed
20610
Arthrocentesis/arthroscopic procedure — non-covered when billed with specified hyaluronic acid J-codes and knee osteoarthritis diagnosis codes
J7318
Hyaluronic acid product (example)
J7320
Hyaluronic acid product (example)
J7321
Hyaluronic acid product (example)
M17
Osteoarthritis of knee (diagnosis code group)
M17.0
Osteoarthritis of knee - diagnosis
M17.1
Osteoarthritis of knee - diagnosis
Behavioral health testing, treatment, and residential codesCPT|HCPCS|RevenueCovered
Prior authorization is required for numerous outpatient surgical procedures. Requests should be submitted prior to the service unless an emergent/stabilization exception applies. Failure to obtain authorization may result in review and potential denial.
Bariatric surgery: 43770, 43772, 43773, 43774 (S2083 no longer requires authorization as of 8/1/22)
Blepharoplasty: 15820-15823
Breast reconstruction/mammoplasty: 11920-11971, 19300, 19316-19342, 19355, 19370-19396 (19303 with breast cancer dx does not require auth)
Skin/dermatological procedures: select codes including 15011,15012,11730 when billed with REV 0360/0361/0490; many in-office POS 11/22 do not require auth; ambulatory surgery POS 24 codes requiring auth include 10040,11300-11313,11400-11471,11721
Specific device/prosthetic and supply codes require auth regardless of POS: A2025-A2045 series, G0681-G0684,11200-11201,11719,15769-15829,17340-17999, Q4354-Q4367, Q4383-Q4440
Freestanding ambulatory surgery center (bill type 0831) preauthorization required for: 10060,11100,17000,20600,20605
20610 is non-covered with hyaluronic acid J-codes and knee osteoarthritis diagnoses; otherwise no auth required
Ear procedures: 69300, 69090
Background and Scope
This document defines Fidelis Care’s utilization management procedures rather than clinical practice guidelines. It specifies which settings, services and billing codes require prior authorization, describes limited notification and concurrent‑review exemptions for certain in‑network OMH and OASAS licensed facilities, and identifies code lists, exclusions, and routing instructions to support authorization and claims processing.
Key Definitions and Tools
LOCADTR
DefinitionLOCADTR clinical review tool used to assess medical necessity and for notification/consultation in OASAS inpatient SUD settings
Use caseFacilities submit LOCADTR information (Appendix A) to qualify for the 28-day concurrent-review exemption; LOCADTR may be used for retrospective or extended reviews after day 28
Submission methodOASAS LOCADTR Appendix A form may be faxed to 833-663-1608 or emailed to LOCADTR@fideliscare.org
OMH Best Practice Manual
DefinitionOMH Best Practice Manual: evidence-based clinical review criteria approved by NYS OMH used to determine clinical necessity and triggers for utilization review in OMH-licensed programs
Application
Policy Summary
PayerFidelis Care
PolicyPrior Authorization and Utilization Management Requirements for Inpatient, Outpatient, Behavioral Health, and Related Services
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for all inpatient admissions (post‑stabilization) and for listed outpatient, transplant, behavioral health, DME and procedural services as specified.
Concurrent-review exemption periodFirst 28 days of inpatient admission are not subject to prior authorization or concurrent utilization review for in-network NY OASAS-licensed facilities
Notification timing and methodFacility must notify Fidelis Care of the admission and initial treatment plan within two (2) business days using the OASAS Appendix A Notification Form and LOCADTR tool (fax to 833-663-1608 or LOCADTR@fideliscare.org)
Ongoing requirementsFacility must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14 to confirm use of LOCADTR; services may be subject to utilization review after day 28
OMH under-18 concurrent-review exemption
Concurrent-review exemption period for under-18sFirst 14 days of inpatient admission are not subject to prior authorization or concurrent utilization review for in-network NY OMH-licensed facilities for members under age 18
Two-business-day notificationFacility must notify Fidelis Care of the admission and initial treatment plan within two (2) business days by completing the OMH 'Two-Day Notification and Initial Treatment Plan' form and submitting by fax (833-561-0094) or email (Mental_Health_Admission@fideliscare.org)
Facility obligationsFacility must perform daily clinical review and participate in periodic consultation to ensure use of OMH-approved evidence-based clinical review criteria
OB ultrasound count
Normal pregnancy ultrasound allowanceThe first 4 OB ultrasounds for a normal pregnancy can be performed without authorization
Authorization thresholdFive (5) or more ultrasounds for a normal pregnancy require prior authorization
High-risk pregnancy ultrasoundsOB ultrasounds for high-risk pregnancies do not require prior authorization
Relevant diagnosis codes (high-risk pregnancy)Examples include O09.00-O09.03, O09.1-O09.13, O36.80X0-O36.80X5 and others listed in the policy
Delegation notePrior authorization for radiology services has been delegated to Evolent (NIA); cardiac ultrasounds are delegated to TurningPoint per other sections
Appendix version/date
Appendix version/date stampV26.0-06/01/2026
Appendix contentAppendix I lists HCPCS/J-codes requiring prior authorization with mapped descriptors and product references
Prior authorization requirementProviders must obtain prior authorization for codes listed in Appendix I prior to billing
Facial cosmetic/septoplasty/rhinoplasty: 21120-21296,30400-30450,30465-30520,30620-30802,30999,31298,Q2028 (TurningPoint-delegated CPTs should be sent to TurningPoint)
Other selected outpatient surgery codes: C1600-C1604, C1737, C7556-C7560, C9807, 15734,15736,15738,25111,27458,27713,28285,28300,28299,28308,29848,23140,52443,54360,55866,60660-60661,64654-64656,64618-64640,64728
Certain outpatient orthopedic and spinal procedures delegated to Evolent (see Provider Actions - Orthopedic/Spinal Procedures)
ENT and Cardiac surgical procedures may require prior authorization; refer to applicable code lists
Prior Authorization
Outpatient and DME Prior Authorization
A broad set of outpatient diagnostic services, durable medical equipment (DME), proprietary laboratory tests, and select procedures require prior authorization. Submit requests to the designated reviewers or vendor per routing instructions. Some services (noted below) do not require authorization.
Diagnostic testing requiring auth: Sleep studies (including home studies), BRCA and certain genetic tests (exceptions: CPT 81220, 81244, 81252, 81329, 81336, 81420), Wireless Capsule Endoscopy 91110-91111, Wireless Motility capsule 91112-91113
Gastroenterology: codes 43235,43239,43248,45378,45380,45384,45385,46255,46260,46270 require auth if performed in POS 19 or 22 when office/ASC (POS 11 or 24 not requiring auth); codes 43290 and 43889 require auth in any POS
Other outpatient services requiring auth: G0571,42975,64567,87182-87183,97007-97009,97037
Imaging studies and selected TBS scans (77089-77092) require authorization per imaging section
Ambulatory CGM: 95249 requires authorization
Prior Authorization
DME Authorization Requirements
Some DME and supplies are exempt from prior authorization while others require prior authorization. Check the code list below before submitting requests.
Donor breast milk (T2101) requires authorization only when given in an outpatient setting
Other DME codes and specific supplies that DO require authorization include but are not limited to: compression garments/stockings, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps and infusion pumps
Blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered under the pharmacy benefit (not DME PA)
Prior Authorization
Chiropractic Prior Authorization
Chiropractic services billed with the codes listed below require prior authorization before services are rendered.
Certain services are routed to external vendors for prior authorization. Follow vendor-specific submission routes and contacts.
Orthodontic and major dental services: prior authorization via DentaQuest at 1-800-516-9615
Vision prior authorizations: Davis Vision at 1-800-601-3383
Oncology medications and supportive agents: prior authorization and review required by Evolent. Submit via Evolent web portal (https://um.newcenturyhealth.com) or call 1-888-999-7713, option 1. Do not send excluded request types (see Pharmacy section exclusions).
Prior Authorization
Codes requiring prior authorization (Appendix I) — partial list
Prior authorization is required for many HCPCS/CPT/J-/Q-/S- and other codes listed in Appendix I prior to billing. Providers must obtain authorization for these codes to avoid denial or non-payment. The Appendix I is lengthy; below is a representative partial list — always check Appendix I for the current complete list.
Representative Q-codes and S-codes included in Appendix I and requiring auth: Q0138-Q0155, Q0224, Q4074, Q5098-Q5159, Q5130-Q5133, and many others; selected S-codes (S0155-S0175, S0160, S0169-S0174, etc.)
Appendix I is the authoritative list for HCPCS/J-codes requiring PA — consult the Appendix and Pharmacy team routing (fax 1-844-235-5090 for Pharmacy PA submissions) before billing
Prior Authorization
Transplants: Authorization Required
All solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation. Lack of authorization may result in denial or non-payment. Refer to the transplant code list and contact Fidelis Care for transplant authorization routing.
Selected transplant-related codes include but are not limited to: 32850-32856 series, 33930-33942 series, 38204-38242 series, 44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757
Authorization must be obtained at the time of transplant evaluation
Prior Authorization
Other outpatient services requiring authorization
Certain select services (e.g., select gastroenterology procedures, wireless capsule endoscopy, penile prosthesis, proprietary labs, and other listed outpatient services) require prior authorization per the outpatient/DME section. Confirm place-of-service rules where noted.
Gastroenterology codes requiring auth in POS 19/22 when office/ASC available: 43235,43239,43248,45378,45380,45384,45385,46255,46260,46270 (no auth when in POS 11 or 24)
43290 and 43889 require auth in any place of service
Transcranial Magnetic Stimulation (TMS) is covered with prior authorization required for CPT codes 90867-90869. Requests may be submitted via email, fax, or by phone following the Behavioral Health prompts. Members must meet eligibility criteria including age (>18), FDA-cleared device use, confirmed MDD diagnosis, and failure to respond to multiple medication trials and evidence-based psychotherapy during the current episode.
TMS CPT codes requiring auth: 90867, 90868, 90869
Submit requests to qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts (ext. 16072)
Member eligibility: age >18, FDA-cleared device used per labeled indication, confirmed major depressive disorder, and inadequate response to multiple medication and psychotherapy trials
Documentation Required
Voicemail HIPAA-compliance requirements for UM messages
Voicemail messages left by Utilization Management (UM) staff may include details only if the provider's voicemail is HIPAA-compliant. The mailbox greeting must identify the mailbox owner and organization and state that the box is confidential and that PHI may be left. If voicemail is not HIPAA-compliant, UM will leave a generic message requesting a callback and will make a second direct attempt as required by Department of Health reasonable effort policies.
HIPAA-compliant voicemail requirements: greeting must identify owner and organization and state mailbox is confidential and PHI may be left
Non-HIPAA-compliant voicemail: UM leaves generic message and requests callback; detailed UM messages will not be left
UM will make a second attempt to reach the provider directly when notifying of a UM determination
Oncology-related prior authorization requests (medications and supportive agents) are routed to Evolent for review. Use Evolent's web portal or phone contact. Certain oncology-related items remain excluded from Evolent review per the Pharmacy section; verify exclusions before submission.
Evolent Oncology Program submission: https://um.newcenturyhealth.com/Account/Logon/frm_LogOn or call 1-888-999-7713, option 1
Oncology meds/supportive agents for outpatient administration or physician office administration require Evolent PA prior to dispensing/administration
Excluded from Evolent review: antibiotics, bone marrow/stem cell transplants, CAR-T therapy, selected drugs and services listed in Pharmacy exclusions (see Pharmacy section)
Pharmacy PA submissions for Appendix I codes: fax 1-844-235-5090
Utilization review in OMH-licensed inpatient, partial hospitalization, and intensive outpatient programs is conducted only for members meeting OMH Best Practice Manual triggers (AOT order, recent AOT, high utilization, 30-day readmission, or LOS >30 days)
Provider actionFacilities must notify Fidelis Care within two business days of admission and follow OMH notification procedures to qualify for exemption periods where applicable
Applied Behavior Analysis (ABA)
DefinitionApplied Behavior Analysis (ABA): a form of enhanced behavioral modification covered for members with Autism Spectrum Disorder and requiring Behavioral Health authorization
Authorization requirementBehavioral Health authorization is required for ABA services
DocumentationAttestation of ASD diagnosis by a licensed physician or psychologist must be provided at time of request
Transcranial Magnetic Stimulation (TMS)
DefinitionTranscranial Magnetic Stimulation (TMS): a covered treatment administered with an FDA-cleared device for adults (>18) with major depressive disorder
CPT codesAuthorization required for CPT codes 90867, 90868, 90869
Eligibility criteriaMember must be over 18, have a confirmed diagnosis of MDD, and have failed multiple medication and evidence-based psychotherapy trials during the current episode