MedicaidCoverageMedium impact
Maryland Medicaid Clinical Coverage Updates for First Quarter 2023 (January- March 2023)
Maryland Medicaid·MD · Oncology, Pediatrics, Endocrinology +4 more·Provider Transmittal
Effective date
Jan 1, 2023
We identified it
Jun 20, 2026
Summary
Maryland Medicaid has approved coverage for six new medications (Netspot, Danyelza, Tzield, Viltepso, Takhsyro, Pedmark), one laboratory test (FoundationOne CDx), and updated coverage guidelines for hyperbaric oxygen therapy, lung cancer screening, and Optune DME. All newly approved services require prior authorization. Effective dates range from January 1, 2023 through April 25, 2023, with billing teams needing to implement these changes immediately in their systems.
Action Required
By October 31, 2023: Billing team must immediately update billing system to add prior authorization requirements for all newly approved medications and services: Netspot (A9587), Danyelza (J9999), Tzield (J3590), Viltepso (J3490), Takhsyro (J3590), Pedmark (J3490), FoundationOne CDx (0037U), Hyperbaric Oxygen Therapy (G0277, 99183), Lung Cancer Screening (71271), and Optune (E0766). Verify that clinical criteria for each service are available at https://bit.ly/3DI2RXG and incorporate into prior authorization workflows. Update encounter templates and provider notices to alert clinicians that prior authorization is required before billing. For medications priced by invoice/report (Danyelza, Tzield, Viltepso, Takhsyro, Pedmark), establish procedures to submit invoices for reimbursement determination. Ensure staff processing claims understand that claims submitted without required prior authorization will be denied. Communicate effective dates to all clinical staff, noting that some services became effective retroactively (January 1, 2023) and others prospectively (April 25, 2023, January 24, 2023).