Medicare Prior Authorization Changes, eff 7/1/2025

Date: 06/04/25

Medicare Prior Authorization Updates Effective 7/1/2025

This notice contains information regarding Medicare prior authorization (PA) requirements and is applicable to Medicare HMO and PPO products

It is the ordering/prescribing provider’s responsibility to determine which specific codes require PA. 

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE PA FOR ALL SERVICES EXCEPT WHERE SPECIFICALLY OTHERWISE INDICATED.       

To confirm Medicare HMO (wellcare by allwell) PA requirements for a specific CPT/HCPCS code, please use the Medicare Pre-Auth Check Tool available on our website www.azcompletehealth.com > For Providers > Pre-Auth Check.

To confirm Medicare PPO (wellcare PPO) PA requirements for a specific CPT/HCPCS code, please use the PA Look Up Tool located at https://www.wellcare.com/arizona/providers/authorization-lookup

Effective July 1, 2025, the following are changes to PA requirements for wellcare PPO: 

Service Category	PA Rule	Service	Procedures Code
Surgery Procedures	PA Required	Skin Grafts	Q4205
Durable Medical Equipment	No PA Required	Neurostimulators	E0730
		Wheelchairs	E0973, E2624

Effective July 1, 2025, the following are changes to PA requirements for wellcare by allwell HMO products: 

Service Category	PA Rule	Service	Procedures Code
Durable Medical Equipment	PA Required	Wheelchairs	E1012
	No PA Required for Par Providers	Neurostimulators	E0720, E0730
		Equipment & Accessories	E0953
		Wheelchairs	E0973, E0990, E1016, E1038, E2210, E2359, E2361, E2363, E2365, E2607, E2624, K0019, K0077, K0733
		Orthotic & Prosthetic	L5617
Drug Codes	PA Required	Specialty Drugs	J9217
Specialty Procedures	PA Required	Skin Grafts	Q4205
Other Medical Services	No PA Required for Par Providers	Wound Care	97605, 97606

If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com