Provider Alert! Updates to Prior Authorization Requirements for CADs, electronic bone growth stimulators, home telemonitoring, and hospital beds

Provider Alert!

Provider Alert! Updates to Prior Authorization Requirements for CADs, electronic bone growth stimulators, home telemonitoring, and hospital beds

Attention: All providers

Effective Date: February 19, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to inform network providers of Prior Authorization updates.

Clinician Administered Drugs (CAD) that require a prior authorization effective February 19, 2021:

  • 90378, Synagis- for all members, available through the pharmacy benefit
  • J7199, Hemophilia Clot Factor
  • J0584    Injection, burosumab-twza, 1 mg  (Crysvita)
  • J1746    Injection, ibalizumab-uiyk, 10 mg (Trogarzo)
  • J3397    Injection, vestronidase alfa-vjbk, 1 mg (Mepsevii)
  • J9269    Injection, tagraxofusp-erzs, 10 mcg (Elzonris)
  • J0129    Injection, abatacept, 10 mg (Orencia)
  • J0220    Injection, alglucosidase alfa, 10 mg, not otherwise specified
  • J0221    Injection, alglucosidase alfa, (Lumizyme), 10 mg
  • J0517    Injection, benralizumab, 1 mg   (Fasenra)
  • J9027    Injection, clofarabine, 1 mg (Clolar)
  • J7311    Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg
  • J2357    Injection, omalizumab, 5 mg  (Xolair)
  • J2786    Injection, reslizumab, 1 mg  (Cinqair)

The following CADs no longer require a prior authorization:

  • C9045   Injection, moxetumomab pasudotox-tdfk, 0.01 mg
  • C9050   Injection, emapalumab-lzsg, 1 mg

Electronic Bone Growth Stimulators that require a prior authorization effective February 19, 2021:

  • E0749 Osteogenesis stimulator, electrical, surgically implanted
  • E0760 Osteogenesis stimulator, low intensity ultrasound, noninvasive

Electronic Bone Growth Stimulators that already require a prior authorization effective September 4, 2020:

  • E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal applications
  • E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications

Home Telemonitoring services that require a prior authorization effective February 19, 2021:

  • 99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • 99422 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
  • 99423 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

Hospital Beds that require a prior authorization effective February 19, 2021:

  • E0184 Dry pressure mattress          `
  • E0185 Gel or gel-like pressure pad for mattress, standard mattress length and width
  • E0186 Air pressure mattress
  • E0187 Water pressure mattress
  • E0188 Synthetic sheepskin pad
  • E0189 Lambswool sheepskin pad, any size
  • E0190 Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories
  • E0193 Powered air flotation bed (low air loss therapy)
  • E0194 Air fluidized bed
  • E0196 Gel pressure mattress
  • E0197 Air pressure pad for mattress, standard mattress length and width
  • E0198 Water pressure pad for mattress, standard mattress length and width
  • E0199 Dry pressure pad for mattress, standard mattress length and width
  • E0371 Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
  • E0372 Powered air overlay for mattress, standard mattress length and width
  • E0373 Nonpowered advanced pressure reducing mattress

Hospital Beds that already require a Prior authorization effective August 26, 2020

  • E0271 Mattress, innerspring- 1 purchase every 5 years
  • E0277 Powered pressure-reducing air mattress, 1 per month
  • E0315 Bed accessory: board, table, or support device, any type
  • E0912 Trapeze bar
  • E0940 Trapeze bar, freestanding
  • E0250 Hospital bed, fixed height, with any type side rails, with mattress- 1 purchase every 5 years; 1 per month rental
  • E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress – 1 purchase every 5 years; 1 per month rental
  • E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress- 1 purchase every 5 years; 1 per month rental
  • E0265 Hospital bed, total electric (head, foot, and height adjustment s), with any type side rails, with mattress- 1 purchase every 5 years; 1 per month rental
  • E0300 Pediatric crib, hospital grade, fully enclosed, with or without top enclosure- 1 per month rental
  • E0316 Safety enclosure frame/canopy for use with hospital bed, any type-1 per month rental
  • E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress-1 per month rental
  • E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring includes mattress-1 per month rental

How this impacts providers: Providers should follow the new prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days.

Next steps for providers: Providers should inform their staff of the new prior authorization requirements.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.

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