Medicare Prior Authorization Changes Effective 7/1/22
Date: 05/30/22
Our Medicare team recently completed a review of the codes listed on the following pages. These updates are applicable to Medicare Wellcare by Allwell plans (does not apply to Wellcare PPO) and are effective 7/1/22.
Prior Authorization Reminders:
1. It’s the ordering/prescribing provider’s responsibility to determine services that require prior authorization.
2. Please use the Pre-Auth Check Tool on our website to confirm if the code(s) requires prior authorization. Prior authorization requirements vary based on the line of business so please select the applicable Pre-Auth Check Tool by line of business: https://www.azcompletehealth.com/providers/preauth-check.html.
3. Please verify eligibility and benefits prior to rendering services for members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered.
4. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED
If you have questions regarding the information contained in this update, please contact our Provider Customer Service Center at (866) 796-0542 or your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at: AzCHProviderEngagement@azcompletehealth.com
Change | Services | Procedure Codes | |
Anesthesia | Add PA | Anesthesia for Spine Manipulation or Closed Proc | 00640 |
Dermatology | Add PA | Skin Tag Removal | 11200, 11201 |
Add PA | Benign Lesion Excision | 11451 | |
Surgical | Add PA | Skin Substitutes & Biologicals | 15271, 15273, 15274,15275, 15277, 15278, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4110, Q4116, Q4121, Q4122, Q4124, Q4126, Q4128, Q4132, Q4133, Q4137, Q4138, Q4148, Q4151, Q4153, Q4154, Q4155, Q4158, Q4159, Q4160, Q4161, Q4163, Q4169, Q4178, Q4183, Q4186, Q4187, Q4195, Q4196, Q4197 |
Add PA | Breast Reconstruction – No PA when billed with breast cancer diagnosis | 19357, 19380 | |
Add PA | Flap Procedures | 15600, 15620, 15630, 15650, 15730, 15731, 15733, 15734, 15736, 15738 | |
Add PA | Suction Assisted Lipectomy | 15877, 15879 | |
Add PA | Blepharoplasty (Lower Eyelid) | 15820 | |
Add PA | Autogenous Rib Cartilage Graft | 21230 | |
Add PA | Temporomandibular joint treatment | 21240, 21242, 21243 | |
Add PA | Malar Augmentation | 21270 | |
Add PA | Unlisted Procedures | 21299, 21899, 41899, 60699 | |
Add PA | Hernia Repair | 49560, 49565, 49652, 49653, 49654, 49656, 49657 | |
Orthopedic | Add PA | Procedures of Upper Extremities | 23405, 23406, 23430, 23485, 24301, 24305, 24341, 24342, 24343, 24344, 24357, 24359, 25111, 25112, 25115, 25118, 25310, 25320, 26480, 26483, 26485, 26498, 29805, 29806, 29820, 29821, 29822, 29823, 29824, 29825, 29828, 29834, 29837, 29838, 29844, 29846 |
Add PA | Procedures of Lower Extremities | 27310, 27380, 27385, 27620, 27696, 27698, 27871, 29891, 29892, 29894, 29895, 29897, 29898 | |
Add PA | Procedures of the foot or toes | 28008, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28306, 28308, 28312 | |
Add PA | Endoscopy (Foot, Wrist) | 29848, 29893 | |
Add PA | Unlisted Procedures | 23929, 27599, 28899, 29799 | |
Pulmonology | Add PA | Unlisted Pulmonary Service | 94799 |
Service Category | Change | Services | Procedure Codes |
Cardiac | Add PA | Cardiac Monitor Insertion | 33285 |
Add PA | Endovenous Ablation | 36473 | |
Add PA | Endovascular Revascularization | 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231 | |
Add PA | Vascular Embolization and Occlusion | 37241, 37242, 37243, 37244 | |
Add PA | Unlisted Vascular Surgery | 37799 | |
Add PA | Intracardiac Catheter Ablation | 93653, 93654, 93656 | |
ENT | Add PA | Sinus Procedures | 30130, 30140, 30560 |
Add PA | Nasal/Sinus Endoscopy | 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31298 | |
Add PA | Palatopharyngoplasty | 42145 | |
Add PA | Osseointegrated Implant | 69714 | |
Add PA | Unlisted ENT Procedure | 30999, 31299, 92700 | |
Gastroenterology | Add PA | Laparoscopy Procedures | 43280, 43281, 43282, 43283 |
Add PA | Unlisted Procedures | 43289, 43499, 43659, 44238, 44799, 44979, 45399, 45999, 46999, 47379, 49329, 49659, 49999 | |
Add PA | Cholecystectomy | 47562, 47563, 47600 | |
Add PA | Exploratory Laparotomy | 49000 | |
Urology | Add PA | Prostrate Procedure | 53850, 53854, 53899, 55899 |
Add PA | Penile Prosthesis | 54408, 54410, 54416 | |
Add PA | Laparoscopy Surgery (Prostrate) | 55866 | |
Neurology | Add PA | Neurostimulators Procedures | 61885, 61886, 64568, 64575, 64999 |
Add PA | Neuroplasty Procedures | 64704, 64708, 64716, 64718, 64719, 64721 | |
Add PA | Sinusoidal Vertical Axis Rotational Testing | 92546 | |
Add PA | EEG/VEEG | 95700, 95711, 95712, 95713, 95714, 95715, 95716 | |
Ophthalmology | Add PA | Corneal Procedures/Transplant | 65730, 65750, 65755, 65756, 65757, 65770 |
Add PA | Glaucoma Procedures/Surgery | 65855, 66170, 66172, 66183, | |
Add PA | Cataract Procedures | 66820, 66821, 66825, 66830, 66840, 66850, 66852, 66940, 66982, 66983, 66984, 66985, 66986, 66987, 66988 | |
Add PA | Repair Procedures of Eye | 67228, 67255, 67912, 67961, 67966, 68761 | |
Add PA | Unlisted Ophthalmological Service/Procedure | 67999, 92499 |
Service Category | Change | Services | Procedure Codes |
Diagnostic radiology | Add PA | Thyroid/Parathyroid Imaging | 78012, 78013, 78014, 78018, 78070, 78071, 78072 |
Add PA | Bone Marrow Imaging | 78102 | |
Add PA | Liver/Spleen & Gallbladder Imaging | 78201, 78202, 78215, 78216, 78226, 78227 | |
Add PA | Radiopharmaceutical Localization of Tumor | 78800, 78802, 78803, 78830, 78831, 78832 | |
Add PA | Unlisted Procedure | 78999 |
Laboratory | Add PA | Genetic Analysis Procedures | 81245, 81246, 81261, 81263, 81264, 81310, 81315, 81340, 81342 |
Add PA | Engraftment Analysis | 81267, 81268 | |
Add PA | Chronic HCV assay | 81596 | |
Add PA | Bone Marrow Culture | 88237 | |
Behavioral Health | Add PA | Transcranial Magnetic Stimulation | 90867 |
Miscellaneous | Add PA | Unlisted Special Service, Procedure, or Report | 99199
|
Part B Drugs | Add PA | Medical Injectables | C9077, C9081, J2506, J2597, J2794, Q2054, Q2055, Q5123 |
Add PA | Inhalation Solutions | J7605, J7606, J7626 | |
Add PA | CAR-T Therapy | 0537T, 0539T, 0540T |