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Medical Pre-authorization

Medicare Products Pre-authorization List
Effective July 1, 2014

Using this list: Click the yellow triangle to expand a collapsed section. To search the page for a specific code, expand all sections, then press Ctrl and f keys to open a search box.

Effective January 1, 2014, refer to our new Medicare Medical Policy manual for information on criteria used to establish medical necessity for Medicare products. The pre-authorization list below is a comprehensive list of all pre-authorization and notification requirements for Medicare members. View the notification about these policies.

How to submit a pre-authorization request or notification of admission

Expedited requests
Expedited is defined as: when the Member or his/her physician believes that waiting for a decision under the standard time frame could place the Member’s life, health, or ability to regain maximum function in serious jeopardy. Expedited requests should be faxed to the number specified below.

Online
Submit a pre-authorization request via this secure online form.

Phone or fax
Submit completed pre-authorization request forms (PDF) to the fax numbers shown below:

Type of Service

Phone Fax
Chemical Dependency and Mental Health 1 (800) 780-7881 1 (888) 496-1540
Medical Inpatient Admissions 1 (800) 824-8563 1 (800) 453-4341
Transplants 1 (800) 824-8563 1 (800) 584-0689
DME and Professional Services 1 (800) 824-8563 1 (855) 232-0088
Expedited Requests 1 (800) 824-8563 1 (855) 240-6498
Radiology Quality Initiative (RQI)

View details on program authorization requirements Employees (and covered dependents) of Kootenai Health using alpha prefix KOL are not subject to the RQI program requirements. Kootenai Health retiree spouses on the Regence EGWP Medicare Advantage plan (alpha prefix ZVG) will be subject to the RQI program.

Physical Medicine View details on program authorization/notification requirements
Sleep Medicine View details on program and authorization requirements

Other Forms

Important Pre-authorization Reminders

  1. Failure to provide notification of inpatient admission or secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Members may not be balance billed.
  2. Before requesting pre-authorization and providing services, please verify member eligibility and benefits. Member contracts determine benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. Urgent/Emergent services do not require pre-authorization, but are subject to hospital admission notification requirements (see below).
  5. Our Medicare Medical Policy, MCG and CMS criteria may be used as the basis for medical necessity determinations, including length of stay and level of care.
  6. Investigational and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be for potentially investigational services and are subject to review.
  7. Please note that a notification or pre-authorization does not guarantee payment for requested services. Our reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits.

Payment implications for failure to timely notify or
pre-authorize services

Payment implications for failure to timely notify or pre-authorize services

Effective with admission dates of service on or after July 1, 2013, failure to provide notification of inpatient admission or secure approval for services subject to pre-authorization will result in claim non-payment and provider liability. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • If the facility follows the inpatient admission and discharge notification requirement indicated above, they will not be subject to any pre-authorization penalties for failure by the physician or other health care professional to pre-authorize a service. We will review for medical necessity.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any penalties for failure of the facility to provide the required inpatient admission and discharge notification. We will review for medical necessity.
  • The following are facility pre-authorization requirements prior to patient admission:
    • Inpatient rehabilitation
    • Skilled nursing facility (SNF) care
    • Long term acute care facility (LTAC) care
    • Residential treatment for mental health and chemical dependency
  • An inpatient admission and discharge notification or pre-authorization do not guarantee payment for requested services. Regence reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be medically necessary.

Notification Timeframe Reimbursement
There will be four situations where exceptions to not obtaining a pre-authorization or failure to notify us of inpatient admissions may apply as part of our Administration Dispute Exception Criteria include:

  1. Member presented with an incorrect member card or member number.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present are able to provide coverage information.
  4. Compelling evidence the provider or facility attempted to obtain pre-authorization or provide hospital admission notification. The evidence shall support the provider or facility followed our policy.

Note: A copy of the provider's or facility's fax cover sheet indicating the member health plan information and a fax confirmation from the fax machine showing the fax was successfully sent to the appropriate health plan fax number will be considered compelling evidence.

Learn how to appeal an administrative denial.

 

Chemical Dependency and Mental Health

MCG is used as the basis for determining medical necessity for Mental Health and Substance Abuse services. Visit MCG’s website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of guidelines for specific services.

Detoxification

Chemical Dependency

Notification is required for all admissions within 24 hours of admission (or one business day, if the admission occurs on a weekend or a federal holiday). We may initiate concurrent review upon notification of admission, or conduct review post-payment.

Notification of patient discharge is required.
Inpatient
Mental Health and Chemical Dependency

Notification is required for all admissions within 24 hours of admission (or one business day, if the admission occurs on a weekend or a federal holiday). We may initiate concurrent review upon notification of admission, or conduct review post-payment.

Notification of patient discharge is required.
Partial Hospitalization
Mental Health and Chemical Dependency

Notification is required for all admissions within 24 hours of admission (or one business day, if the admission occurs on a weekend or a federal holiday). We may initiate concurrent review upon notification of admission, or conduct review post-payment.

Notification of patient discharge is required.
Intensive Outpatient
Mental Health and Chemical Dependency

Notification is required for all admissions within 24 hours of admission (or one business day, if the admission occurs on a weekend or a federal holiday). We may initiate concurrent review upon notification of admission, or conduct review post-payment.

Notification of patient discharge is required.
Outpatient
Mental Health and Chemical Dependency

We may initiate concurrent review upon notification of admission, or conduct review post-payment.

Inpatient Admissions

Elective inpatient admissions

Pre-authorization is required for all elective inpatient admissions.

  • An elective admission is an admission of a patient for care or treatment which, in the opinion of the treating clinician, is necessary and admission can be delayed for at least 24 hours.
  • Authorization of inpatient facility stays, including level of care and length of stay, will be issued at the same time as authorization for the professional service.
  • Maternity admissions do NOT require pre-authorization by the delivering provider.

Hospital admissions, including inpatient hospice, maternity and newborn

Notification is required for all hospital admissions within 24 hours of admission (or one business day, if the admission occurs on a weekend or a federal holiday). Maternity and newborn admissions require notification at the time of delivery. Regence may initiate concurrent review upon notification of admission, or conduct review post-payment.

Notification of patient discharge is required via fax unless arrangements have been made to provide access to the information via an electronic medical record application. Learn more about this requirement.

Long Term Acute Care Facility (LTAC)

Pre-authorization required prior to patient admission.

Acute Rehabilitation

Pre-authorization required prior to patient admission.

Skilled Nursing Facility (SNF) - sometimes referred to as "sub-acute rehabilitation"

Pre-authorization required prior to patient admission.

SNF is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.

Professional Services

Allied Health

Biofeedback

90875, 90876, 90901, 90911

E0746

Durable Medical Equipment

Wheelchairs, Mobility Assistive Equipment (MAE), and Power Mobility Devices (Power Operated Vehicles [POV] and Power Wheelchairs [PWC])

E0973, E1002, E1004, E1006, E1007, E1028, E1161, E1220, E2310, E2311, E2312, E2313, E2328, E2330, E2370, E2373, E2374, E2375, E2377, E2607, E2609, E2611, E2615, E2617, E2620

K0008, K0013, K0806, K0822, K0823, K0824, K0825, K0835, K0839, K0848, K0849,  K0851, K0856, K0858, K0861, K0884

Negative Pressure Wound Therapy Pumps

A6550, A9270, E2402, K0743, K0744, K0745, K0746

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders

A7025, A7026, E0483, E0484

Speech Generating Devices (SGD)

E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512

Automatic External Defibrillators

E0617, K0606, K0607, K0608, K0609

Pneumatic Compression Devices E0650, E0651, E0652, E0655, E0660, E0665, E0666, E0667, E0668, E0669, E0671, E0672, E0673
Myoelectric Prosthetic Components for the Upper Limb L6025, L6715, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191
Powered Knee Prosthesis, or Powered Ankle-Foot Prosthesis, and Microprocessor-Controlled Ankle-Foot Prosthesis L5859, L5969, L5973
Functional Neuromuscular Electrical Stimulation E0731, E0745, E0764, E0770
Electrostimulation and Electromagnetic Therapy for the Treatment of Wounds in the Home Setting G0329
View the Sleep Medicine Management Program for other authorization requirements through AIM Specialty HealthSM (AIM) Review the Sleep Medicine Management Program CPT Code List (PDF)

Genetic Testing

Genetic and Molecular Diagnostics

81161, 81200, 81201, 81202, 81203, 81205, 81206, 81207, 81208, 81209, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81235, 81240, 81241, 81242, 81243, 81244, 81245, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81275, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81315, 81316, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81340, 81341, 81342, 81350, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81504, 81507, 88363

G9143

Laboratory

Medicine

Apheresis (Therapeutic Pheresis) 36511, 36512, 36513, 36514, 36515, 36516
In Vivo Analysis of Colorectal Polyps 88375
Epiretinal Radiation Therapy for Age-Related Macular Degeneration 67036
Intensity Modulated Radiation Therapy (IMRT) 77301, 77338, 77418, 0073T
Hyperbaric Oxygen Therapy 99183, C1300
Radioembolization for Primary and Metastatic Tumors of the Liver

37243, 75894, 79445

C2616

Orthopedic Applications of Stem-Cell Therapy 38206, 38230, 38241
Signal-Averaged Electrocardiography (SAECG) 93278
Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting 93701
Charged-Particle (Proton or Helium Ion) Radiation Therapy 77520, 77522, 77523, 77525
Neurofeedback 90875, 90876, 90901
External Counterpulsation (ECP) Therapy for Severe Angina G0166, 92971
Extracorporeal Photopheresis 36522
Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions G0460, P9020
Ocular Photodynamic Therapy (OPT)

67221, 67225

T-Wave Alternans 93025
Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions 28890
View the Sleep Medicine Management Program for other authorization requirements through AIM Specialty HealthSM (AIM) Review the Sleep Medicine Management Program CPT Code List (PDF)

Radiology

Surgery

Endometrial Ablation 58353, 58356, 58563
Cochlear Implant

69930

L8614, L8619, L8627, L8628

Varicose Vein Treatment 36468, 36469, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785
Percutaneous Angioplasty and Stenting of Veins 35476, 37238, 37239, 75978
Gastric Electrical Stimulation

43647, 43648, 43881, 43882, 64590, 64595, 95980, 95981, 95982,

C1767, C1778, C1883, C1897

E0765

L8679

Cosmetic and Reconstructive Procedures

11920, 11921, 11922, 15788, 15820, 15821, 15822, 15823, 15789, 15792, 15793, 15830, 17106, 17107, 17108, 17360, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 21740, 21742, 21743, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 41510, 49250, 49560, 49565, 54360, 57291, 57292, 57295, 57296, 57426, 67900, 67901, 67903, 67904, 67908, 67902, 67906, 67909, 67950

G0429, Q2026, Q2028

Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

Implantable Bone-Conduction and Bone-Anchored Hearing Aids

69714, 69715, 69717, 69718

L8690, L8691

Temporomandibular Joint (TMJ) Surgical Interventions 21010, 21050, 21240, 21242, 21243, 29800, 29804
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence 53860
Cryosurgical Ablation of Miscellaneous Solid Organ and Breast Tumors 19105, 31641, 55873
Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction

64561, 64581, 64585, 6459

L8679, L8681, L8682, L8683, L8684

Orthognathic Surgery for Conditions Other Than Sleep Apnea

21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21230, 21215

Endovascular Angioplasty and/or Stenting for Intracranial Arterial Disease (Atherosclerosis and Aneurysms) 61630, 61635
Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome 37241, 75894
Surgical Ventricular Restoration 33548
Posterior Tibial Nerve Stimulation for Voiding Dysfunction

64566

Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435

G0173, G0251, G0340, G0339

Femoroacetabular Impingement (FAI) Surgery 29914, 29915, 29916
Transanal Endoscopic Microsurgery (TEMS) 0184T
Surgical Treatments for Hyperhidrosis 32664, 64818, 69676
Surgery for Sleep Apnea, Snoring, and Upper Airway Resistance Syndrome 21121, 21122, 21141, 21145, 21196, 21199, 21198,, 21685, 42140, 42145, 42160, 41512, 41530, 41120, 41500,
Implantable Cardiac Defibrillators

33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249

0319T, 0320T, 0321T, 0322T, 0323T, 0324T, 0325T, 0326T, 0327T, 0328T

C1721, C1722, C1882

Endoscopic Radiofrequency Ablation or Cryoablation of Barrett's Esophagus 43229, 43270
Microwave Tumor Ablation 47382, 50592, 76940
Occipital Nerve Stimulation

61885, 61886, 64553, 64585,64555, 64568, 64569

L8679, L8681, L8682, L8683

Open and Thoracoscopic Approaches to Treat Atrial Fibrillation (Maze and Related Procedures) 33256, 33257, 33259
Autologous Fat Grafting to the Breast and Adipose-derived Stem Cells 19366, 11950, 11951, 11952, 11954
Gastric Reflux Surgery 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337
Lung Volume Reduction Surgery 32491, G0302, G0303, G0304, G0305
Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants

11920, 11970, 11971 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396

L8600

Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

Spinal Cord Stimulation for Treatment of Pain

63650, 63655, 63685

L8679

Bariatric Surgery 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43645
Reduction Mammaplasty

19318

Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

Brachytherapy: Non-Intracoronary 19296, 19297, 19298, 0182T
Vagus Nerve Stimulation

61885, 61886, 61888, 64553, 64568, 64569

L8679, L8681, L8682, L8683

0314T, 0315T

Deep Brain Stimulation

61850, 61860, 61863, 61864, 61867, 61868

L8679, L8681, L8682, L8683, 61885, 61886

Radiofrequency Ablation of Tumors (RFA) 20982, 31641, 47370, 47380, 47382, 50542, 50592, 76940, 77013, 77022
Extracranial Carotid Angioplasty/Stenting 37215
View Physical Medicine Program for spinal pre-authorization requirements through CareCore National

Review the Medicare Advantage Spinal Surgery Code List (PDF)

Transplants and Ventricular Assist Devices

Artificial Hearts and Ventricular Assist Devices 33975, 33976, 33977, 33978, 33979, 33980, 33981, 33982, 33983, 33990, 33991, 33993, 0048T, 0050T, 0051T, 0052T, 0053T, Q0478, Q0479, Q0480, Q0481, Q0482, Q0483, Q0484, Q0485, Q0486, Q0487, Q0488, Q0489, Q0490, Q0491, Q0492, Q0493, Q0494, Q0495, Q0496, Q0497, Q0498, Q0499, Q0500, Q0501, Q0502, Q0503, Q0504, Q0506, Q0507, Q0508, Q0509
Heart Transplants 33940, 33944, 33945
Heart/Lung Transplants 33930, 33933, 33935
Liver Transplants 47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147
Pancreas Transplants 48550, 48551, 48552, 48554
Lung Transplants 32850, 32851, 32852, 32853, 32854, 32855, 32856
Intestinal and Multi-Visceral Transplant 44132, 44133, 44135, 44136, 44715, 44720, 44721, 47133, 47135, 47136, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 48550, 48551, 48552, 48554
Islet Cell Transplantation 48160, G0343, G0341, G0342
Stem Cell / Bone Marrow Transplants 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242

Utilization Management

Elective Air Ambulance Transport

Emergency air ambulance transports will be reviewed retrospectively for medical necessity; please submit clinical documentation and rationale for this form of transportation with your claim.

A0140, A0430, A0431, A0435, A0436

Radiology Quality Initiative

We have partnered with AIM Specialty Health to administer our Radiology Quality Initiative (RQI) program and full utilization management for our members. View details on program requirements. Employees (and covered dependents) of Kootenai Health using alpha prefix KOL are not subject to the RQI program requirements. Kootenai Health retiree spouses on the Regence EGWP Medicare Advantage plan (alpha prefix ZVG) will be subject to the RQI program.

Physical Medicine

We have partnered with CareCore National, LLC (CCN) to administer a physical medicine program for our members including pre-authorization of spinal procedures. View details on program requirements.

Sleep Medicine

We have partnered with AIM Specialty Health to administer our sleep medicine management program and full utilization management for our members. View details on program requirements.