Medicare AdvantagePrior AuthMedium impact
[California] Precertification/prior authorization change to the parenteral nutrition codes listed
Anthem BCBS·CA · Gastroenterology, General Surgery, Critical Care +2 more·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 27, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross will require precertification/prior authorization for 20 parenteral nutrition 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 California. Claims lacking prior authorization or not meeting CMS LCD L38953 criteria (permanently nonfunctioning gastrointestinal tract) will be denied.
Action Required
By July 1, 2026: Billing team must update billing software to require prior authorization for all 19 parenteral nutrition HCPCS codes (B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4187, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200) for Anthem Medicare Advantage members in California only. Before submitting claims, obtain precertification through Availity Essentials by verifying the patient has a permanently nonfunctioning gastrointestinal tract per CMS LCD L38953. Update provider encounter forms and templates to prompt documentation of gastrointestinal tract status. Train billing staff and providers on new requirements. Communicate with ordering providers that claims without prior authorization or failing to meet medical necessity criteria will be denied. Use Availity Essentials or Provider Services (number on member ID card) for authorization requests and appeals.