What documentation does Anthem require for CPT 96365?

Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts); Documentation of prior treatment failures for second-line indications; Prescribing physician specialty relevant to condition; Requested dose, frequency, and duration; Site of care justification if hospital outpatient

How much does Medicare pay for CPT 96365 in 2026?

In 2026, the national Medicare allowable for CPT 96365 is $67.14 in an office setting and $67.14 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.

What if Anthem denies the PA for CPT 96365?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Anthem Prior Authorization for CPT 96365

IV infusion for therapy, prevention, or diagnosis, initial up to 1 hour · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Anthem clinical policy

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Anthem requires prior authorization for IVIG infusion. Approved for primary immunodeficiency, CIDP (NCS-confirmed, failed corticosteroids), ITP (platelets <30K, failed steroids), Guillain-Barre syndrome, myasthenia gravis crisis. Dose must follow published guidelines. Site of care optimization required (home infusion or outpatient center preferred). Submit via Carelon.

Documentation checklist

✓Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts)
✓Documentation of prior treatment failures for second-line indications
✓Prescribing physician specialty relevant to condition
✓Requested dose, frequency, and duration
✓Site of care justification if hospital outpatient

Submission channels

Phone

1-800-274-7767

2026 Medicare rate for CPT 96365

Office (non-facility)

$67.14

Facility

$67.14

Total RVUs (office)

2.01

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Anthem's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 96365 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts), Documentation of prior treatment failures for second-line indications, Prescribing physician specialty relevant to condition….
3Submit via phone, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Anthem require prior authorization for CPT 96365?: Yes. Anthem requires prior authorization for CPT 96365 (IV infusion for therapy, prevention, or diagnosis, initial up to 1 hour) under Standard commercial plans per its published clinical policy.
What documentation does Anthem require for CPT 96365?: Confirmed diagnosis with supporting lab values (immunoglobulin levels, NCS, platelet counts); Documentation of prior treatment failures for second-line indications; Prescribing physician specialty relevant to condition; Requested dose, frequency, and duration; Site of care justification if hospital outpatient
How much does Medicare pay for CPT 96365 in 2026?: In 2026, the national Medicare allowable for CPT 96365 is $67.14 in an office setting and $67.14 in a facility. Commercial allowables for Anthem are typically negotiated against this benchmark.
What if Anthem denies the PA for CPT 96365?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Anthem PA lookups

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CPT 96365 prior authorization by payer

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