Medicare AdvantagePrior AuthMedium impact
[New York] Precertification/prior authorization requirement changes
Anthem BCBS·NY · Oncology, Pain Management, Gastroenterology +2 more·Provider Bulletin
Effective date
Dec 1, 2026
We identified it
Aug 8, 2026
Summary
Effective December 1, 2026, Anthem Medicare Advantage in New York is adding prior authorization requirements for five new service codes: a prostate cancer biomarker test (0591U), genicular nerve destruction procedure (64624), electronic transanal irrigation system (A4479), digital cognitive/behavioral therapy (A9294), and microprocessor-controlled ankle orthosis addition (L2221). All claims for these services will require precertification before processing, and claims submitted without prior auth approval may be denied.
Action Required
By November 15, 2026: Billing team must update billing system and EMR templates to require prior authorization for CPT/HCPCS codes 0591U, 64624, A4479, A9294, and L2221 for all Anthem Medicare Advantage members in New York. For each service ordered: (1) Front desk/scheduling staff must verify insurance and initiate prior auth request through Availity Essentials or call Anthem Provider Services at 800-450-8753 before the service is rendered; (2) Providers must document medical necessity in the patient record; (3) Billing team must not submit claims without auth approval on file. Failure to obtain prior authorization will result in claim denials and may make services ineligible for payment. Providers may appeal denials by submitting additional medical records through Availity or by phone.