Material Adverse Change (MAC)

The following services will be added to precertification for the effective dates listed below.

 

To submit precertification, providers can access Availity Essentials* at www.availity.com. Service preapproval is based on member’s benefit plan/eligibility at the time the service is reviewed/approved.

 

Precertification can help avoid unnecessary charges or penalties by helping to ensure that the member's care is medically necessary and administered at an appropriate network facility and by a network provider.

 

Criteria

Criteria description

Codes

Effective date

LAB.00019

Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

0014M

April 1, 2023

LAB.00011

Selected Protein Biomarker Algorithmic Assays

0080U

April 1, 2023

LAB.00011

Selected Protein Biomarker Algorithmic Assays

0092U

April 1, 2023

LAB.00019

Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

0166U

April 1, 2023

LAB.00011

Selected Protein Biomarker Algorithmic Assays

0174U

April 1, 2023

LAB.00011

Selected Protein Biomarker Algorithmic Assays

0247U

April 1, 2023

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

0248U

April 1, 2023

LAB.00011

Selected Protein Biomarker Algorithmic Assays

0249U

April 1, 2023

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

0278T

April 1, 2023

LAB.00015

Detection of Circulating Tumor Cells

0317U

April 1, 2023

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

0324U

April 1, 2023

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

0325U

April 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

0483T

April 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

0484T

April 1, 2023

SURG.00104

Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

0510T

April 1, 2023

SURG.00104

Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis

0511T

April 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

0544T

April 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

0545T

April 1, 2023

MED.00103

Automated Evacuation of Meibomian Gland

0563T

April 1, 2023

LAB.00003

In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

0564T

April 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

0569T

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0587T

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0588T

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0589T

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

0590T

April 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

0646T

April 1, 2023

MED.00004

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

0658T

April 1, 2023

MED.00004

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

0700T

April 1, 2023

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

0720T

April 1, 2023

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

33928

April 1, 2023

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

33995

April 1, 2023

SURG.00047

Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

43236

April 1, 2023

SURG.00047

Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

43497

April 1, 2023

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

64555

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

64561

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

64566

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

64581

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

64585

April 1, 2023

LAB.00019

Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease

81596

April 1, 2023

MED.00002

Selected Sleep Testing Services

95803

April 1, 2023

MED.00092

Automated Nerve Conduction Testing

95905

April 1, 2023

MED.00004

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

96931

April 1, 2023

MED.00004

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

96932

April 1, 2023

MED.00004

Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

96933

April 1, 2023

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

C1767

April 1, 2023

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

C1778

April 1, 2023

SURG.00158

Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain

C1787

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

C1820

April 1, 2023

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

C1823

April 1, 2023

SURG.00124

Carotid Sinus Baroreceptor Stimulation Devices

C1825

April 1, 2023

CG-SURG-95

Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

C1883

April 1, 2023

CG-DME-44

Electric Tumor Treatment Field (TTF)

E0766

April 1, 2023

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

K1002

April 1, 2023

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

K1023

April 1, 2023

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield.


NYBCBS-CM-012055-22



Featured In:
January 2023 Newsletter