2021 Allwell Prior Authorization List Updates

Date: 11/17/20

Allwell from Arizona Complete Health requires prior authorization as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Allwell from Arizona Complete Health.

Allwell from Arizona Complete Health is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria.

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

Effective January 1, 2021, prior authorization will be required for the services as listed on page 2 through 7.

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 services are rendered. Non-participating providers and facilities require prior authorization for all HMO services except where indicated.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool on Health Plan website at https://www.azcompletehealth.com/providers/preauth-check/medicare-pre-auth.html.

ADDITIONAL INFORMATION

If you have questions regarding the information contained in this update, or need your assigned Provider Engagement Specialist contact information please email AzchProviderEngagement@azcompletehealth.com.

Service Category	Services/Procedures	Comments
Service Category	Services/Procedures	Comments
Acupuncture	An alternate form of medicine in which thin needles are inserted into the body. Medicare doesn't cover acupuncture (including dry needling) for any condition other than chronic low back pain. Limit to 20 visits	Prior Auth Required: • Health Net Medicare Advantage for California • Arizona Complete Health • Oregon Health Net Medicare Advantage • Allwell from MHS - MHS Indiana • Allwell from Sunflower • Allwell from Louisiana Healthcare Connections • Allwell from Superior HealthPlan (MA & MMP) • Allwell Medicare Advantage from MHS Health Wisconsin • Ascension Complete (FL, IL, KS) Contracted Providers: Visit ashlink.com Non-Contracted providers: Call (800) 972-4226
Ambulance Nonemergent Fixed Wing	Requires prior authorization before transport
Behavioral Health Services	Day Treatment
	Electroconvulsive Therapy (ECT)
	Inpatient Psychiatric
	Intensive Outpatient Therapy
	Neuropsychological Testing
	Partial hospitalization
	Psychological Testing
	Substance Use Disorder Treatment/Rehabilitation
Bronchial Thermoplasty	Outpatient procedure for the treatment of asthma


Chiropractor Services	Medicare coverage for chiropractic services extends only to treatment by means of manual manipulation of the spine to correct a subluxation, provided such treatment is reasonable and medically necessary	Prior Auth Required: • Health Net Medicare Advantage for California • Arizona Complete Health • Oregon Health Net • Allwell from Louisiana Healthcare Connections Contracted Providers: Visit ashlink.com Non-Contracted providers: Call (800) 972-4226
Clinical Trials: Notification Only	A clinical trial is one type of clinical research that follows a pre-defined plan or protocol
Cochlear Implants & Surgery	Provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea
Cosmetic Procedures/Dermatology	Includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member Including, but not limited to the following:
	Chemical exfoliation, electrolysis
	Dermabrasion/chemical peel
	Laser treatment
	Skin injections and implants
Drug Testing	Quantitative tests for drugs of abuse
Durable Medical Equipment (DME)	Ambulatory Infusion Pumps
	BIPAP
	Bone Growth Stimulator
	Continuous Glucose Monitor
	Hospital Bed/Mattress
	Implantable Neurostimulator
	Lift Devices including Hoyer
	Lymphedema Pumps and Supplies
	TENS Units
	Vagus Nerve Stimulator
	Ventilators
	Wheelchairs, Custom
	Wheelchairs, Power
	Wound Vacuum (Negative Pressure) Devices


Enhanced External Counterpulsation (EECP)	The noninvasive outpatient treatment for patients with coronary artery disease (CAD)
Experimental/Investigational Services	Any item or service potentially considered investigational or experimental must be authorized in advance
Gender Reassignment	General term to describe a surgery or surgeries that affirm a person's gender identity
Genetic Counseling and Testing	Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins
Infertility	Drug Therapy, Testing, Treatment
Home Health Services	Home Health Aide
	Occupational Therapy
	Physical Therapy
	Skilled Nursing Visits
	Social Work Visits
	Speech Therapy
Hospice: Notification only	Home or Inpatient
Hospital Admission	Acute Inpatient Hospital
	Inpatient Rehabilitation Hospital
	Long Term Acute Care Hospital (LTAC)
	Skilled Nursing Facility (SNF)
Hyperbaric O2 Therapy	Includes HBO therapy administered in a chamber
Neuropsychological Testing	Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning
Nutritional Supplements and/or services	Formula administered via a enteral feeding tube
Observation Stay	Prior Authorization required if >48 hours
Orthotics/Prosthetics	Prosthetic devices needed to replace a body part or function
Orthotics/Prosthetics	Limited coverage options for orthotic shoes and devices, including artificial limbs and eyes as well as braces for arms, legs, back, or neck, penile prosthetics
Enhanced External Counterpulsation (EECP)	The noninvasive outpatient treatment for patients with coronary artery disease (CAD)

Experimental/Investigational Services	Any item or service potentially considered investigational or experimental must be authorized in advance
Gender Reassignment	General term to describe a surgery or surgeries that affirm a person's gender identity
Genetic Counseling and Testing	Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins
Infertility	Drug Therapy, Testing, Treatment
Home Health Services	Home Health Aide
	Occupational Therapy
	Physical Therapy
	Skilled Nursing Visits
	Social Work Visits
	Speech Therapy
Hospice: Notification only	Home or Inpatient
Hospital Admission	Acute Inpatient Hospital
	Inpatient Rehabilitation Hospital
	Long Term Acute Care Hospital (LTAC)
	Skilled Nursing Facility (SNF)
Hyperbaric O2 Therapy	Includes HBO therapy administered in a chamber
Neuropsychological Testing	Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning
Nutritional Supplements and/or services	Formula administered via a enteral feeding tube
Observation Stay	Prior Authorization required if >48 hours
Orthotics/Prosthetics	Prosthetic devices needed to replace a body part or function
Orthotics/Prosthetics	Limited coverage options for orthotic shoes and devices, including artificial limbs and eyes as well as braces for arms, legs, back, or neck, penile prosthetics
Outpatient Therapy	Therapeutic treatment: as a remedial treatment of mental or bodily disorder or	Requires authorization after 12 combined visits
· Occupational Therapy	an agency (as treatment) designed or
· Physical Therapy	serving to bring about rehabilitation or social adjustment
· Speech-Language Therapy

Pain Management	Facet Injections
	Median Branch Block
	Radio Frequency Ablation
	Sacroiliac joint injection (SI)
	Trigger Point
Part B Drugs		See attached Appendix A
Radiation Therapy	Intensity modulated radiotherapy (IMRT)
	Neutron beam therapy
	Proton beam therapy
	Stereotactic radiotherapy
Radiology	Cardiac Imaging	All Health Plans Excluding Allwell Medicare Advantage from MHS Health Wisconsin visit www.radmd.com
	CT
	MRA
	MRI, MRA, PET Scan, CT, Cardiac Imaging
	PET
Sleep Studies	Surgery and treatment Hospital Sleep Study
Surgeries, regardless of place of service	Abortion
	Bariatric Surgery
	Blepharoplasty
	Breast Augmentation (except following mastectomy)
	Breast Reduction
	Capsule Endoscopy
	Chondrocyte Implants
	Cochlear Implant
	Facial Osteotomy
	Hysterectomy
	Joint Replacements
	Mastectomy for Gynecomastia


Surgeries, regardless of place of service continued	Oral Surgery -- Temporomandibular Joint Surgery Otoplasty
	Reconstructive and Plastic Surgery
	Rhinoplasty
	Sacral Nerve Neuromodulation
	Septoplasty
	Spinal Surgeries including Fusion, Stabilization, Discectomy
	Uvulopalatopharyngoplasty/ Uvolopharyngoplasty
	Veins (ablation, ligation, stripping, sclerotherapy)
	X-Stop: Spinal Surgery
Transplants	All transplant evaluations and procedures, including but not limited to evaluation, transplant consult visits, HLA typing, donor search and transplant procedure