MedicaidCoverageMedium impact
Maryland Medicaid Clinical Coverage Updates for the Second Quarter 2023 April-June 2023
Maryland Medicaid·MD · Oncology, Ophthalmology, Pediatrics +3 more·Provider Transmittal
Effective date
Jul 1, 2023
We identified it
Jun 20, 2026
Summary
Maryland Medicaid has approved four new covered services effective July-August 2023: Pylarify (PET imaging for prostate cancer), Syfovre (complement inhibitor for macular degeneration), Elevidys (gene therapy for pediatric Duchenne muscular dystrophy), and transcervical radiofrequency ablation for uterine fibroids. Additionally, Spinraza clinical criteria have been updated to remove timing restrictions, and 17-OHPC is no longer recommended for preterm birth prevention. All require prior authorization.
Action Required
By July 1, 2023: Billing team must update billing system to recognize and require prior authorization for Pylarify (A9595) and updated Spinraza (J2326) claims. By August 1, 2023: Add Syfovre (J3490), Elevidys (J3490, J3591), and transcervical uterine fibroid ablation (0404T) to the covered services list with prior authorization requirements. Verify that prior authorization workflows are configured in billing software and EMR systems. Update clinical staff to discontinue use of 17-OHPC for preterm birth prevention. Reference the attached FFS clinical criteria and MCO-specific preauthorization requirements. Obtain prior authorization documentation before claim submission; claims submitted without authorization will be subject to MCO denial policies. Contact mdh.professionalservicespolicy@maryland.gov with questions.