Medicare AdvantagePrior AuthMedium impact
[California] Prior authorization requirement changes
Anthem BCBS·CA · Orthopedics, Neurosurgery, PM&R (Physical Medicine & Rehab) +1 more·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Effective May 1, 2026, Anthem Medicare Advantage plans in California will require prior authorization for 11 new billing codes related to bone strength analysis, neurostimulator procedures, spinal orthoses, and lower extremity prosthetics. Billing teams must update their systems to request precertification before submitting claims for these services to Medicare Advantage members, or claims will be denied.
Action Required
By April 1, 2026: Billing team must update billing software and encounter forms to require prior authorization from Anthem before submitting claims for CPT codes 0554T, 0555T, 0556T, 0557T, 0558T, 0743T, 64595, and HCPCS codes G0130, J3402, J3403, L1499, L5657 for all Anthem Medicare Advantage (HMO, C-SNP, I-SNP) members in California. Configure system to flag these codes for precertification requirement and route requests through Availity Essentials or Provider Services. Train billing and clinical staff on new requirements. Failure to obtain prior authorization will result in claim denials and member liability.