CurrentFidelis CarePolicy N/A

Fidelis Care Cardiac and ENT Code Scope (selected CPT/HCPCS codes)

Lists CPT and HCPCS procedure codes under Fidelis Care's 2026 Cardiac and ENT code scope and indicates whether prior authorization (PA) is required for each listed code. Affects providers billing Fidelis Care for these procedures.

Policy Summary

PayerFidelis Care

PolicyFidelis Care Cardiac and ENT Code Scope (selected CPT/HCPCS codes)

Policy CodePolicy N/A

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing for listed Cardiac and ENT procedures, check the table for the PA indicator — codes shown in green do not require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70+procedure codes listed

ManyPA not required

Cardiac & ENTscope

Coverage and Authorization Summary

The following CPT and HCPCS codes are included in Fidelis Care's 2026 Cardiac and ENT code scope and do not require prior authorization (PA).

Choanal Atresia: CPT 30540 — Repair Choanal Atresia; Intranasal (No PA required).

Choanal Atresia: CPT 30545 — Repair Choanal Atresia; Transpalatine (No PA required).

Cochlear Implant: CPT 69930 — Implant Cochlear Device (No PA required).

Cochlear Implant: HCPCS L8614 — Cochlear Device, Includes All Internal And External Components (No PA required).

Functional Endoscopic Sinus Surgery (FESS): CPT 31240 — Nasal/Sinus Endoscopy, Surgical; With Concha Bullosa Resection (No PA required).

Policy Summary

PayerFidelis Care

PolicyFidelis Care Cardiac and ENT Code Scope (selected CPT/HCPCS codes)

Policy CodePolicy N/A

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionWhen billing for listed Cardiac and ENT procedures, check the table for the PA indicator — codes shown in green do not require prior authorization.

SourceLink

On This Page

Selected CPT and HCPCS Codes

Selected CPT/HCPCS codes from Cardiac and ENT listmixed

30540	Repair Choanal Atresia; Intranasal
30545	Repair Choanal Atresia; Transpalatine
69930	Implant Cochlear Device
L8614	Cochlear Device, Includes All Internal And External Components

Myringotomy / Tympanostomy codesmixed

69420	Myringotomy Including Aspiration And/Or Eustachian Tube Inflation
69421	Myringotomy Requiring General Anesthesia
69433	Tympanostomy (Insertion Of Ventilating Tube), Local Or Topical
69436	Tympanostomy Requiring General Anesthesia

mixed

No codes listed

Coding metadata

Thresholds presentNone specified in the document (threshold fields empty)

Effective / Review datesNot provided in source or brief

Code list countApproximately 70+ procedure CPT/HCPCS codes referenced across the Cardiac and ENT scope

Document statusCURRENT

Provider Billing and Authorization Actions

Prior Authorization

Prior Authorization Note — Selected Cardiac & ENT Codes

Selected Cardiac and ENT procedure codes listed below do not require prior authorization when billed appropriately. Providers should verify member benefits and site-specific rules before scheduling.

HCPCS/CPT Codes in Green — No PA Required: CPT 30540, CPT 30545, CPT 69930, HCPCS L8614, CPT 31240

Documentation Required

Documentation and Provider Action Highlights

Keep detailed documentation in the medical record to support the indication for each procedure. At minimum include: history and physical, diagnostic findings (imaging/endoscopy/audiology as applicable), prior conservative treatments and their durations, and operative reports. Submit the operative report and any relevant diagnostic test results with the claim or authorization request when applicable. Failure to provide supporting documentation may result in claim denial or delays.

Required documentation with claim/PA request: history and physical; diagnostic test results (e.g., imaging, endoscopy, audiology); documentation of prior conservative therapy and dates; operative report.
If a code is listed as "No PA Required" verify member coverage and include supporting documentation in the medical record to substantiate medical necessity.

Scope Definitions and PA Indicators

HCPCS/CPT code scope / PA indicator

Code scopeFidelis 2026 Cardiac and ENT Code Scope (selected CPT/HCPCS procedure codes)

PA indicatorMany lines show the phrase 'HCPCS Codes in Green No PA Required' indicating PA not required for those codes

Example CPT codes30540, 30545, 69930, 31240

Example HCPCS codeL8614

Additional definitions / metadata

Definition: HCPCS/CPT code scopeIndicates which CPT and HCPCS procedure codes are included in Fidelis 2026 Cardiac and ENT Code Scope

Definition: PA status wordingThe document uses the phrase 'HCPCS Codes in Green No PA Required' to mark codes that do not require prior authorization

Related policy impactApplies to providers billing Fidelis Care for procedures in the Cardiac and ENT scope