Medicare Prior Authorization List Effective January 1, 2021

Medicare Prior Authorization List Effective January 1, 2021

Allwell from Superior HealthPlan (HMO and HMO SNP) requires prior authorization as a condition of payment for many services. This notice contains information regarding prior authorization requirements and is applicable to all Medicare products offered by Allwell. Allwell is committed to delivering cost effective quality care to 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. Please note: Prior authorization is subject to covered benefit review and is not a guarantee of payment. Effective January 1, 2021, Prior Authorization will be required for the following services:

Allwell.

SHP_20207187A

Medicare Prior Authorization List Effective January 1, 2021

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 AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please visit Superior's Medicare Prior Authorization Tool.

Service Category

Acupuncture

Ambulance Nonemergent Fixed Wing Behavioral Health Services Bronchial Thermoplasty

Services/Procedures

Comments

Prior Authorization Required:

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

? 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)

Requires prior authorization before transport

Day Treatment Electroconvulsive Therapy (ECT) Inpatient Psychiatric Intensive Outpatient Therapy Neuropsychological Testing Partial hospitalization Psychological Testing Substance Use Disorder Treatment/Rehabilitation Outpatient procedure for the treatment of asthma

Contracted Providers: Visit Non-Contracted providers: Call 877-248-2746

Medicare Prior Authorization List Effective January 1, 2021

Service Category

Services/Procedures

Comments

Prior Authorization Required:

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

Clinical Trials: Notification Only Cochlear Implants & Surgery

Cosmetic Procedures/Dermatology

Drug Testing

Durable Medical Equipment (DME)

A clinical trial is one type of clinical research that follows a pre-defined plan or protocol

Provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea 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

Quantitative tests for drugs of abuse

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

? Health Net Medicare Advantage for California

? Arizona Complete Health ? Oregon Health Net ? Allwell from Louisiana Healthcare

Connections

Contracted Providers: Visit Non-Contracted providers: Call 877-248-2746

Medicare Prior Authorization List Effective January 1, 2021

Service Category

Services/Procedures

Comments

Enhanced External Counterpulsation (EECP) Experimental/Investigational Services Gender Reassignment Genetic Counseling and Testing Infertility

Home Health Services

Hospice: Notification only

Hospital Admission

Hyperbaric O2 Therapy

Neuropsychological Testing Nutritional Supplements and/or services Observation Stay

Orthotics/Prosthetics

The noninvasive outpatient treatment for patients with coronary artery disease (CAD)

Any item or service potentially considered investigational or experimental must be authorized in advance General term to describe a surgery or surgeries that affirm a person's gender identity Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins Drug Therapy, Testing, Treatment

Home Health Aide

Occupational Therapy

Physical Therapy

Skilled Nursing Visits

Social Work Visits

Speech Therapy Home or Inpatient

Acute Inpatient Hospital

Inpatient Rehabilitation Hospital

Long Term Acute Care Hospital (LTAC)

Skilled Nursing Facility (SNF) Includes HBO therapy administered in a chamber Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning Formula administered via a enteral feeding tube

Prior Authorization required if >48 hours Prosthetic devices needed to replace a body part or function 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

Medicare Prior Authorization List Effective January 1, 2021

Service Category

Services/Procedures

Comments

Outpatient Therapy Occupational Therapy Physical Therapy Speech-Language Therapy Pain Management Part B Drugs Radiation Therapy

Radiology Sleep Studies

Surgeries, regardless of place of service

Therapeutic treatment: as a remedial treatment of mental or bodily disorder or an agency (as treatment) designed or serving to bring about rehabilitation or social adjustment

Facet Injections Median Branch Block Radio Frequency Ablation Sacroiliac joint injection (SI) Trigger Point

Intensity modulated radiotherapy (IMRT) Neutron beam therapy Proton beam therapy Stereotactic radiotherapy Cardiac Imaging CT MRA MRI, MRA, PET Scan, CT, Cardiac Imaging PET

Surgery and treatment Hospital Sleep Study 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

Requires authorization after 12 combined visits

See Appendix A at the end of this document.

All Health Plans Excluding Allwell Medicare Advantage from MHS Health Wisconsin visit

Medicare Prior Authorization List Effective January 1, 2021

Service Category

Services/Procedures

Comments

Surgeries, regardless of place of service continued

Transplants

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

All transplant evaluations and procedures, including but not limited to evaluation, transplant consult visits, HLA typing, donor search and transplant procedure

Medicare Part B PA List - Attachment A Effective January 1, 2021

Part B Drugs: STEP THERAPY

Drug Code Drug Name Action

C9050 C9122 J0129 J0178 J0570 J0585 J0717 J0718 J0791 J0800 J0896 J0897 J1300 J1428 J1429 J1442 J1447 J1459 J1555 J1556 J1557 J1558 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599 J1602 J1745 J1930 J2323 J2350 J2353 J2357 J2503 J2505 J2507 J2778 J2786 J2796 J2820 J3111 J3304 J3357 J3380 J3396 J7311 J7312 J7313 J7314 J7318 J7320 J7321 J7322 J7323 J7324 J7325 J7326 J7327 J7328 J7329 J7331 J7332 J7333 J7401 J9022 J9145 J9173 J9176 J9308

Remove Remove

Add

Last Updated Date

Effective Date (if available)

Drug Description

INJECTION, EMAPALUMAB-LZSG, 1 MG

MOMETASONE FUROATE SINUS IMPLANT 10 MCG SINUVA

ABATACEPT INJECTION

AFLIBERCEPT INJECTION

BUPRENORPHINE IMPLANT 74.2MG

INJECTION,ONABOTULINUMTOXINA

CERTOLIZUMAB PEGOL INJ 1MG

CERTOLIZUMAB PEGOL INJ

INJECTION CRIZANLIZUMAB-TMCA 5 MG

INJECTION, CORTICOTROPIN, UP TO 40 UNITS

INJECTION LUSPATERCEPT-AAMT 0.25 MG

DENOSUMAB INJECTION

ECULIZUMAB INJECTION

INJECTION ETEPLIRSEN 10 MG

INJECTION GOLODIRSEN 10 MG

INJ FILGRASTIM EXCL BIOSIMIL

INJECTION, TBO-FILGRASTIM, 1 MICROGRAM

INJ IVIG PRIVIGEN 500 MG

INJECTION IMMUNE GLOBULIN 100 MG

INJ, IMM GLOB BIVIGAM, 500MG

GAMMAPLEX INJECTION

INJECTION IMMUNE GLOBULIN XEMBIFY 100 MG

HIZENTRA INJECTION

GAMUNEX-C/GAMMAKED

INJECTION; IMMUNE GLOBULIN 10%, 5 GRAMS

INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. P

OCTAGAM INJECTION

GAMMAGARD LIQUID INJECTION

FLEBOGAMMA INJECTION

INJ IG/HYALURONIDASE 100 MG IG

IVIG NON-LYOPHILIZED, NOS

GOLIMUMAB FOR IV USE 1MG

INJ INFLIXIMAB EXCL BIOSIMILR 10 MG

1/1/2021

INJECTION, LANREOTIDE, 1 MG

NATALIZUMAB INJECTION

INJECTION OCRELIZUMAB 1 MG

1/1/2021

INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG

INJECTION, OMALIZUMAB, 5 MG

INJECTION, PEGAPTANIB SODIUM, 0.3 MG

INJECTION, PEGFILGRASTIM, 6 MG

PEGLOTICASE INJECTION

RANIBIZUMAB INJECTION

INJECTION RESLIZUMAB 1MG

ROMIPLOSTIM INJECTION

INJECTION, SARGRAMOSTIM (CM-CSF), 50 MCG

INJECTION ROMOSOZUMAB-AQQG 1 MG

INJECT TRIAMCINOLONE ACETONIDE PF ER MS F 1 MG

USTEKINUMAB FOR SUBQ INJECTION 1 MG

INJECTION VEDOLIZUMAB 1 MG

INJECTION, VERTEPORFIN, 0.1 MG

INJECTION FA INTRAVITREAL IMPL 0.01 MG

DEXAMETHASONE INTRA IMPLANT

INJECTION FA INTRAVITREAL IMPL 0.01 MG

INJECTION FA INTRAVITREAL IMPL 0.01 MG

HYALURONAN/DERIVATIVE DUROLANE FOR IA INJ 1 MG

HYALURONAN/DERIVITIVE GENVISC 850 IA INJ 1 MG

HYAL HYALGN SUPARTZ/VSCO-3 IA INJ-D

HYALURONAN/DRIV HYMOVIS IA INJ 1 MG

EUFLEXXA INJ PER DOSE

ORTHOVISC INJ PER DOSE

SYNVISC OR SYNVISC-ONE

GEL-ONE

MONOVISC INJ PER DOSE

HYAL/DERIV GELSYN-3 IA INJ 0.1 MG

HYALURONAN/DERIVATIVE TRIVISC FOR IA INJ 1 MG

HYALURONAN/DERIVATIVE SYNOJOYNT IA INJ 1 MG

HYALURONAN/DERIVATIVE TRILURON IA INJ 1 MG

HYALURONAN/DERIVATIVE VISCO-3 IA INJ PER DOSE

MOMETASONE FUROATE SINUS IMPLANT 10 MCG

INJECTION ATEZOLIZUMAB 10 MG

INJECTION DARATUMUMAB 10 MG

INJECTION DURVALUMAB 10 MG

INJECTION ELOTUZUMAB 1MG

INJECTION RAMUCIRUMAB 5 MG

Comments

J9311 J9312 J9355 J9356 J9358 Q2041 Q2042 Q2043 Q5101 Q5103 Q5104 Q5107 Q5108 Q5109 Q5110 Q5111 Q5112 Q5113 Q5114 Q5115 Q5116 Q5117 Q5118 Q5119 Q5120 Q5121 Q9991 Q9992

Part B: Prior AuthorizatioDrug Code Drug Name Action

892 A9513 C9035 C9036 C9037 C9038 C9040 C9043 C9044 C9045 C9049 C9050 C9051 C9052 C9053 C9054 C9055 C9056 C9057 C9058 C9061 C9063 C9122 C9130 C9133 C9134 C9136 C9399 C9399 J0129 J0135 J0178 J0179 J0180 J0202 J0220 J0221 J0222 J0223 J0256 J0257 J0364 J0490 J0517 J0567 J0570 J0584 J0585 J0586 J0587 J0588 J0591

Remove Remove Remove Remove

Remove

INJECTION RITUXIMAB 10 MG AND HYALURONIDASE

INJECTION RITUXIMAB 10 MG

INJECTION TRASTUZUMAB EXCLUDES BIOSIMILAR 10 MG

INJECTION TRASTUZUMAB 10 MG AND HYALURONIDASE-OYSK

INJECTION FAM-TRASTUZUMAB DERUXTECAN-NXKI 1 MG

KTE-C19 TO 200 M A ANTI-CD19 CAR POS T CE P TD

TISAGENLECLEUCEL TO 600 M CAR-POS VI T CE PER TD

SIPLEUCEL-T AUTO CD54+

INJECTION, FILGRASTIM-SNDZ, BIOSIMILAR, (ZARXIO)

INJECTION, INFLECTRA

INJECTION, RENFLEXIS

INJECTION BEVACIZUMAB-AWWB BIOSIMILAR 10 MG

INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG

INJECTION INFLIXIMAB-QBTX BIOSIMILAR 10 MG

INJECTION, FILGRASTIM-AAFI, BIOSIMILAR, (NIVESTYM), 1 MICROGRAM

INJECTION, PEGFILGRASTIM-CBQV, BIOSIMILAR, (UDENYCA), 0.5 MG

INJECTION TRASTUZUMAB-DTTB BIOSIMILAR 10 MG

INJECTION TRASTUZUMAB-PKRB BIOSIMILAR 10 MG

INJECTION TRASTUZUMAB-DKST BIOSIMILAR 10 MG

INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG

INJECTION TRASTUZUMAB-QYYP BIOSIMILAR 10 MG

INJECTION TRASTUZUMAB-ANNS BIOSIMILAR 10 MG

INJECTION, BEVACIZUMAB-BVZR, BIOSIMILAR, (ZIRABEV), 10 MG

INJ RITUXIMAB-PVVR BIOSIMILAR RUXIENCE 10 MG

INJ PEGFILGRASTIM-BMEZ BIOSIMLR ZIEXTENZO 0.5 MG

INJ INFLIXIMAB-AXXQ BIOSIMILAR AVSOLA 10 MG

BUPRENORPH XR 100 MG OR LESS

BUPRENORPHINE XR OVER 100 MG

Last Updated Date

Effective Date (if available)

Drug Description

SPECIAL PROCESSED DRUGS - FDA APPROVED GENE THERAPY

LUTETIUM LU 177 DOTATATE THERAPEUTIC 1 MCI

INJECTION ARIPIPRAZOLE LAUROXIL 1 MG

INJECTION PATISIRAN 0.1 MG

INJECTION RISPERIDONE 0.5 MG

INJECTION MOGAMULIZUMAB-KPKC 1 MG

INJECTION FREMANEZUMAB-VFRM 1 MG

INJECTION LEVOLEUCOVORIN 1 MG

INJECTION CEMIPLIMAB-RWLC 1 MG

INJECTION MOXETUMOMAB PASUDOTOX-TDFK 0.01 MG

INJECTION, TAGRAXOFUSP-ERZS, 10 MCG

INJECTION, EMAPALUMAB-LZSG, 1 MG

INJECTION, OMADACYCLINE, 1 MG

INJECTION, RAVULIZUMAB-CWVZ, 10 MG

INJECTION CRIZANLIZUMAB-TMCA 1 MG

1/1/2021

INJECTION LEFAMULIN XENLETA 1 MG

INJECTION BREXANOLONE 1 MG

1/1/2021

INJECTION GIVOSIRAN 0.5 MG

1/1/2021

INJECTION CETIRIZINE HCL 1 MG

1/1/2021

INJECTION PEGFILGRASTIM-BMEZ BIOSIMILAR 0.5

INJECTION TEPROTUMUMAB-TRBW 10 MG

INJECTION EPTINEZUMAB-JJMR 1 MG

MOMETASONE FUROATE SINUS IMPLANT 10 MCG SINUVA

1/1/2021

INJ IMMUNE GLOBULIN BIVIGAM 500 MG

FACTOR IX RECOMBINANT

FACTOR XIII A-SUBUNIT RECOMB

FACTOR VIII (ELOCTATE)

UNCLASSIFIED DRUGS OR BIOLOGICALS

UNCLASSIFIED DRUGS OR BIOLOGICALS

ABATACEPT INJECTION

INJECTION, ADALIMUMAB, 20 MG

AFLIBERCEPT INJECTION

INJECTION BROLUCIZUMAB-DBLL 1 MG

INJECTION, AGALSIDASE BETA, 1 MG

INJECTION ALEMTUZUMAB 1 MG

ALGLUCOSIDASE ALFA INJECTION

LUMIZYME INJECTION

INJECTION PATISIRAN 0.1 MG

INJECTION GIVOSIRAN 0.5 MG

ALPHA 1 PROTEINASE INHIBITOR

GLASSIA INJECTION

INJECTION APOMORPHINE HYDROCHLORIDE 1 MG

BELIMUMAB INJECTION

INJECTION BENRALIZUMAB 1 MG

INJECTION CERLIPONASE ALFA 1 MG

BUPRENORPHINE IMPLANT 74.2MG

INJECTION BUROSUMAB-TWZA 1 MG

INJECTION,ONABOTULINUMTOXINA

ABOBOTULINUMTOXINA

INJ, RIMABOTULINUMTOXINB

INCOBOTULINUMTOXIN A

INJECTION DEOXYCHOLIC ACID 1 MG

Comments

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download