Medicare AdvantagePrior AuthMedium impact
[Virginia] Precertification/prior authorization change to the parenteral nutrition codes listed
Anthem BCBS·VA · Gastroenterology, Critical Care, General Surgery +4 more·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 27, 2026
Summary
Effective July 1, 2026, Anthem will require prior authorization for 20 parenteral nutrition HCPCS codes (B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200) for Medicare Advantage members in Virginia. Prior authorization will be based on CMS LCD L38953 criteria, requiring documentation of a permanently nonfunctioning gastrointestinal tract. Claims submitted without prior authorization or that fail to meet medical necessity criteria will be denied.
Action Required
By June 30, 2026: Billing team must update billing system to require prior authorization for all 20 parenteral nutrition codes (B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200) when billing Anthem Medicare Advantage plans in Virginia. Clinical staff must ensure all parenteral nutrition claims include documentation of permanently nonfunctioning gastrointestinal tract per CMS LCD L38953 criteria. Configure billing system to prevent claim submission without prior authorization approval. Train providers and billing staff that claims submitted without prior authorization or failing to meet LCD criteria will be denied. Use Availity Essentials or contact Anthem Provider Services to submit prior authorization requests with supporting medical records.