Medicare - Provider - 11-5-2019

Medicare Pre-authorization List

This pre-authorization list includes services and supplies that require pre-authorization or notification for Medicare Advantage products.

How to submit a pre-authorization request or notification

Please use the online form or pre-authorization request form below to ensure the most current version is utilized as forms are subject to change. If your Medicare patient requests a service or item that you know or expect is non-covered, please follow our Medicare pre-authorization process to request a pre-service organization determination.

Expedited requests

Use this process only 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.

  • Availity Provider Portal: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request
  • Via fax using the appropriate pre-authorization request form below

Non-covered services

If your Medicare Advantage patient requests a service or item you expect to be non-covered (including those that are statutorily excluded by Medicare, or non-covered by the member's Medicare Advantage plan), you can request a pre-service determination by submitting our pre-authorization request form by phone or fax. Note: Do not submit them via the Availity electronic authorization tool. You must follow our Medicare pre-authorization process for a pre-service organization determination in order for services to be considered for approval and for you to be able to bill the member for services that are not covered. This process replaces the former Advanced Beneficiary Notification (ABN) process for Medicare Advantage.

Within 14 calendar days, we will approve or deny the request, and provide notification to you and the member. A denial notice will include the reason and explain the appeal process. If you wish to appeal a denial on behalf of the member, you must also have a completed Appointment of Representative form (Form CMS-1696).

Radiology program

Codes requiring authorization are listed in the Radiology section below. View a list of groups and products that participate in this program (PDF).

Obtain an order number with AIM Specialty Health:

Physical Medicine

Codes requiring authorization are listed in the Physical Medicine section below. View a list of groups and products that participate in this program (PDF).

Obtain or verify an authorization with eviCore healthcare

Sleep Medicine

Codes requiring authorization are listed in the Sleep Medicine section below. View a list of groups and products that participate in this program (PDF).

Obtain an order number with AIM Specialty Health:

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
  2. Before requesting pre-authorization and providing services, please verify member eligibility and benefits via the Availity Provider Portal as the member contract determines the covered benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  5. Emergency services do not require pre-authorization, but notification should be provided for all hospital admissions or discharges within 24 hours of admission or discharge (or one business day, if the admission occurs on a weekend or a federal holiday).
  6. 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.
  7. Experimental and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially experimental services and are subject to review. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Please refer to the Always Not Medically Necessary Denials list for additional information.
  8. Please note that a notification or pre-authorization does not guarantee payment for requested services. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
  9. Pre-authorization requirements are not dependent upon site of service. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete information.
Pre-authorization review timeframes
Type of reviewTimeframeAdditional time allowed for review if additional information is needed:
Urgent72 hoursNone
Standard initial14 calendar days

Regence provider: None
Non-Regence provider: 14 calendar days

Concurrent24 hours72 hours
Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Notification of inpatient admission should be provided to the health plan. Urgent/emergent services are subject to review post-service for medical necessity; please submit proper clinical documentation with claim.

Please note the following:

  • Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient. Additionally, the pre-authorization should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  • A pre-authorization does not guarantee payment for requested services. Health Plan 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.
  • If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility/provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.

Use PreManage for notification

We receive admissions and discharge information through PreManage.

Inpatient admissions

See below for chemical dependency and mental health admissions.

Hospital admissions

  • Pre-authorization is required for elective inpatient admissions occurring on or after May 1, 2019. For more information, read our Frequently Asked Questions (PDF).
  • Notification of a hospital admissions or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
  • Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided via fax. Learn more about this requirement. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

Inpatient hospice

  • Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
  • Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided via fax. Learn more about this requirement. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

Long Term Acute Care Facility (LTAC)

  • Pre-authorization required prior to patient admission.

Acute Rehabilitation (PDF)

  • Pre-authorization required prior to patient admission.

Skilled Nursing Facility (SNF) (PDF)

  • 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.

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • Regence requires the facility to notify us when ECMO is initiated on a Regence Member. We will initiate concurrent review upon this notification.

Home health care

Pre-authorization is not required for the first episode of home health care.

Pre-authorization is required for subsequent episodes of care, starting with the second episode of care.

Pre-authorization requests should be submitted three to five days before the subsequent episode begins. Requests should include the original Outcome and Assessment Information Set (OASIS) and the completed medication reconciliation form, both signed by the physician. Documentation of a verbal or signed order from the ordering provider is also needed to show provider is in agreement with the continued plan of care.

Note: A single full-length episode of care is defined as a period of 60 consecutive days, not by the number of individual home health visits. A second subsequent episode would start on the first day after the initial episode is completed—the 61st day after the first service was delivered—regardless of whether a service will be delivered on the 61st day. Episodes may be shorter than 60 days; for example, if a member transfers to another home health agency or is discharged and readmitted to the same home health agency.

The home health agency is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.

View the Medicare Advantage medical policy for Home Health Services (PDF).

Chemical dependency and mental health

Pre-authorization is required for the services listed below. Emergency inpatient services do not require pre-authorization but are subject to admission notification requirements.

  • Inpatient: Psychiatric or ASAM 4.0 Detoxification - Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for Substance Use Disorders - Request for authorization is required no later than the day of admission.
  • Intensive outpatient: Psychiatric or ASAM level 2.1 for Substance Use Disorders - Request for authorization is required no later than the day of admission.

View our resources for behavioral health facilities and our behavioral health medical policies.

Clinical trials, Investigational Device Exemption (IDE) studies, and Coverage with Evidence Development (CED) studies and registries
Clinical trial, registry or studyContact and coverage summary
IMPORTANT NOTE: Services in the following categories that are not listed as requiring pre-authorization elsewhere on this page do not require pre-authorization. In addition, the following guidelines may apply to these services, and should be fully reviewed. We recommend confirming coverage with Medicare and/or the health plan. Providers are expected to only submit claims for medically reasonable and necessary services per Title XVIII of the Social Security Act §1862(a)(1)(A).
Category A and Category B Investigational Device Exemption (IDE) studies

Coverage for CMS-approved Category A and B IDE studies includes routine care items and services. Category B IDE devices are also reimbursable, but reimbursement for Category A devices under investigation is statutorily excluded.

View the Medicare Advantage medical policy for Category A and Category B Investigational Device Exemption (IDE) Studies (PDF)

Coverage with Evidence Development (CED) studies and registries

Medicare determines coverage requirements and restrictions for services covered under the CED provision. These services generally have a national coverage determination (NCD) available, and approved studies and registries are added to the CMS clinical trials/registry web site.

View the Medicare Advantage medical policy for Coverage with Evidence Development (CED) Studies and Registries (PDF)

Clinical trials or registries (not otherwise specified)

Medicare determines coverage for clinical trials, including for Medicare Advantage beneficiaries. We recommend providers call Medicare directly at 1-800-MEDICARE to determine Medicare approval status of the requested clinical trial/registry.

View the Medicare Advantage medical policy for Clinical Trials/Registries (PDF)

Durable medical equipment

Commode Chairs with Seat Lift Mechanism (PDF)

  • E0170, E0171

Continuous Glucose Monitors (CGMs) and External Insulin Infusion Pumps (CGM) Systems (PDF)

  • K0553, K0554
    Effective November 1, 2019: E0784

Electrical Stimulation and Electromagnetic Therapy Devices (PDF)

  • E0731, E0745, E0761, E0764, E0770, G0329

Multi-Positional Patient Transfer System (PDF)

  • E0636, E1035, E1036

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)

  • L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L8701, L8702

Noninvasive Ventilators in the Home Setting (PDF)

  • Effective November 1, 2019: E0466

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (PDF)

  • A7025, A7026, E0483

Pneumatic Compression Devices (PDF)

  • E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673

Power Wheelchairs (PWCs) (PDF)

  • K0856, K0861
  • Effective November 1, 2019: K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0857, K0858, K0858, K0859, K0860, K0862, K0863, K0864

Powered Knee, Powered Ankle-Foot, Microprocessor-Controlled Ankle-Foot and Microprocessor-Controlled Knee Prostheses (PDF)

  • L5859, L5973 L5856, L5857, L5858

Sleep Medicine

  • View the Sleep Medicine Program for notification or authorization requirements
  • Review the codes requiring authorization or notification in the sleep medicine section on this list.

Speech Generating Devices (SGD) (PDF)

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

Tumor Treatment Field Therapy (TTFT) (PDF)

  • E0766

Genetic testing

Genetic and Molecular Diagnostics - Single Gene or Variant Testing (PDF)

  • 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81340, 81341, 81342, 81343, 81344, 81345, 81350, 81355, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81422, 81504, 81507, 81519, 81538, G9143, 0009U, 0016U, 0017U, 0023U, 0027U, 0031U, 0032U, 0046U, 0049U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0080U

Genetic and Molecular Diagnostics - Next Generation Sequencing and Genetic Panel Testing (PDF)

  • 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81340, 81341, 81342, 81343, 81344, 81345, 81350, 81355, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81493, 81504, 81507, 81518, 81519, 81520, 81521, 81525, 81538, 81539, 81540, 81541, 81545, 81551, 0009M, 0011M, 0005U, 0018U, 0022U, 0026U, 0029U, 0030U, 0033U, 0034U, 0037U, 0045U, 0047U, 0068U, 0081U, 0086U, 0090U, 0097U, 0101U, , 0109U, 0111U, 0112U, 0129U, 0130U, 0138U

Medicine

Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions (PDF)

  • G0460, P9020

Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting (PDF)

  • 33289, 93264, 93701 C2624

Charged-Particle (Proton) Radiotherapy (PDF)

  • 77520, 77522, 77523, 77525

Gait Analysis (PDF)

  • 96000, 96001, 96002, 96003, 96004

Gender Affirming Interventions for Gender Dysphoria (PDF)

  • 15775, 15776, 17380, 55970, 55980
  • Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
  • 17999, 19303, 19304, 19316, 19318, 19324, 19325,19350, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58180, 58260, 58262,58270, 58275, 58290, 58291, 58353, 58356, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58563, 58570, 58571, 58572, 58573, C1813, L8600
  • Use code 17999 to request laser hair removal.
  • Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to abdominoplasty, breast reconstruction, blepharoplasty, brow lift, chin implants, collagen injections, endometrial ablation, panniculectomy, and rhinoplasty. Check for codes in other areas of this pre-authorization list.

Hyperbaric Oxygen (HBO) Therapy (PDF)

  • 99183 G0277

Intensity Modulated Radiation Therapy (IMRT) (PDF)

  • 77301, 77338 G6015, G6016

In Vivo Analysis of Colorectal Polyps (PDF)

  • 88375

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF)

  • 38206, 38232, 38241

Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE) (PDF)

  • 37243, 79445 C2616

Signal-Averaged Electrocardiography (SAECG) (PDF)

  • 93278

Surface Electromyography (SEMG) Including Paraspinal SEMG (PDF)

  • 96002, 96004

Sleep Medicine

  • View the Sleep Medicine Program for notification or authorization requirements
  • Review the codes requiring authorization or notification in the Sleep medicine section.

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (PDF)

  • 90867, 90868, 90869

Physical Medicine

We partner with eviCore healthcare (eviCore) to administer our Physical Medicine program.

  1. Verify member benefits and eligibility on the Availity Portal
  2. Review this entire page for similar services that require pre-authorization
  3. Determine whether a member participates in this program (PDF)
  4. Obtain or verify an authorization with eviCore:

Physical therapy, speech therapy, occupational therapy (PT,ST,OT); complementary and alternative medicine

  • We require authorization from eviCore for these codes. View a list of groups and products that participate in this program (PDF).
  • Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF) for enrolled dependents aged 17 and younger.
  • 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97127, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283, G0515, S9152

Pain management

  • We require authorization from eviCore for these codes. View a list of groups and products that participate in this program (PDF).
  • 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685, 63688, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72275, 72285, 72295, G0259, G0260

Joint management

  • We require authorization from eviCore for these codes.
  • Note: Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program. Follow these steps to determine which program an ASO member participates in:

  1. Review the Physical Medicine program (eviCore) requirements: View a list of groups and products that participate in this program (PDF). Currently, only a few ASO groups participate in the Joint management component. If the ASO group does not participate, go to step 2.
  2. Review our Surgery authorization requirements: If an ASO group does not participate in the Physical Medicine program, review the Surgery section below for other pre-authorization requirements.

  • 23470, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27416, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916

Spine

  • We require authorization from eviCore for these codes.
  • Note: Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program. Follow these steps to determine which program an ASO member participates in:

  1. Review the Physical Medicine program (eviCore) requirements: View a list of groups and products that participate in this program (PDF). Currently, only a few ASO groups participate in the Spine component. If the ASO group does not participate, go to step 2.
  2. Review our Surgery authorization requirements: If an ASO group does not participate in the Physical Medicine program, review the Surgery section below for other pre-authorization requirements.

  • 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749

Radiology

Contact Regence for pre-authorization for the following codes:

Single Photon Emission Computed Tomography (SPECT) of the Brain (PDF)

  • 78607

AIM Specialty Health

We partner with AIM to administer our radiology program which has two components: Radiology Quality Initiative (RQI) and Advanced Imaging Authorization. Please note, ASO groups who do not participate in the Advanced Imaging component still require an order number through the RQI component. View a list of groups and products that participate in this program (PDF).

Contact AIM to obtain an order number for the following codes:

  • 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 77046, 77047, 77048, 77049, 77078, 77084, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, G0297, 0501T, 0502T, 0503T, 0504T

Sleep Medicine

We partner with AIM to administer our Sleep Medicine program.

Contact AIM to obtain an order number for the following codes:

  • 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601, G0398, G0399, G0400

Surgery

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)

  • 19366
  • Notes:
  • Codes 11950, 11951, 11952, 11954, 19366, 19380, 19499, and 20926 are considered not medically necessary when used for autologous fat grafting with adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.
  • Codes 11950, 11951, 11952, 11954, and 19366 require pre-authorization for other services on this pre-authorization list.

Automated Percutaneous and Percutaneous Endoscopic Discectomy (PDF)

  • 62380, C2614

Balloon Dilation of the Eustachian Tube (PDF)

  • C9745

Bone-Conduction and Bone-Anchored Hearing Aid (BAHA) Implantation, Replacement, and Upgrades (PDF)

  • 69714, 69715, 69717, 69718, L8690, L8691, L8694

Cosmetic and Reconstructive Procedures (PDF)

  • 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15830, 15847, 15876, 15877, 15878, 15879, 17106, 17107, 17108, 17360, 19300, 19355, 21244, 21245, 21246, 21248, 21249, 21280, 21282, 21295, 21296, 21740, 21742, 21743, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 41510, 49250, 49560, 49565, 49654, 49656, 54360, 67900, 67901, 67902, 67903, 67904, 67908, 67906, 67909, 67950, G0429, Q2026, Q2028
  • Codes 11950, 11951, 11952, 11954 and 19366 always require pre-authorization regardless of diagnosis. In addition, please see the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section.
  • 15734: Pre-authorization required only for Component Separation Technique (CST) performed for incisional or ventral hernias without documentation of obstruction or gangrene (diagnosis codes K43.2 or K43.9).
  • Effective March 1, 2020: Pre-authorization for 15734 required only with diagnosis code K43.0, K43.1, K43.2 K43.6, K43.7 or K43.9 for component separation technique (CST)
  • Codes 21245, 21246, 21248 and 21249 are also found in the Medicare Dental Services Medical Policy.
  • Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty) (PDF)

  • 62292

Endometrial Ablation (PDF)

  • 58353, 58356, 58563

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • Please see the Inpatient Admission section for further information.

Gastric Electrical Stimulation (PDF)

  • 43647, 43881, 64590, C1767, C1778, C1883, C1897
  • E0765

Gastroesophageal Reflux Surgery (PDF)

  • 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337

Hypoglossal Nerve Stimulation (PDF)

  • 64568

Lung Volume Reduction Surgery (LVRS, or Reduction Pneumoplasty) (PDF)

  • 32491, 32672, G0302, G0303, G0304, G0305

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF)

  • C9734, C9747, 0398T

Occipital Nerve Stimulation (ONS) (PDF)

  • 64553, 64555, 64568, 64575, 64590

Orthognathic Surgery (PDF)

  • 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, 21295, 21296
  • Codes 21145, 21196, 21198 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF)

  • 37241

Percutaneous Axial Lumbosacral Interbody Fusion (LIF) (PDF)

  • 22586

Percutaneous Left Atrial Appendage Closure (LAAC) (PDF)

  • 33340
  • Important Note: Medicare NCD requires participation in a Medicare-approved trial or registry for coverage eligibility. To facilitate reviews, the assigned 8-digit national clinical trial (NCT) number of the registry or study (found on the ClinicalTrials.gov website) must be included with all requests. Failure to provide the NCT number could result in delays or inaccurate reviews.

Percutaneous Transluminal Angioplasty (PTA) and Stenting (PDF)

  • 37215, 37217, 37238, 37239, 37246, 37247, 37248, 37249, 61635

Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS) (PDF)

  • 64555, 64575, 64590, C1778

Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)

  • C1823

Posterior Tibial Nerve Stimulation (PTNS) (PDF)

  • 64566

Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF)

  • 20982, 31641, 32998, 50542, 50592

Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants (PDF)

  • 11920, 11921, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 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.
  • Codes 11950, 11951, 11952, 11954 and 19366 always require pre-authorization regardless of diagnosis. In addition, please see the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section.

Reduction Mammaplasty (Mammoplasty) (PDF)

  • 15877, 19318
  • Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

Sacral Nerve Modulation/Stimulation for Pelvic Floor Dysfunction (PDF)

  • 64561, 64581, 64590, C1767

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)

  • 21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 41512, 41530, 42140, 42145, 42160
  • Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1. C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Surgical Treatments for Hyperhidrosis (PDF)

  • 32664, 64818, 69676

Surgical Ventricular Restoration (PDF)

  • 33548

Temporomandibular Joint (TMJ) Surgical Interventions (PDF)

  • 21010, 21050, 21240, 21242, 21243, 29800, 29804

Transcatheter Aortic Valve Replacement (TAVR) (PDF)

  • 33361, 33362, 33363, 33364, 33365, 33366
  • Important Note: Medicare NCD requires participation in a Medicare-approved trial or registry for coverage eligibility. To facilitate reviews, the assigned 8-digit national clinical trial (NCT) number of the registry or study (found on the ClinicalTrials.gov website) must be included with all requests. Failure to provide the NCT number could result in delays or inaccurate reviews.

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF)

  • 43192, 43201, 43236

Vagus Nerve Stimulation (VNS) (PDF)

  • 64553, 64568

Varicose Vein Treatment (PDF)

  • 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785
  • Note: Code 37241 is not appropriate to use in the coding of varicose vein treatment

Physical Medicine Program

  • View Physical Medicine Program for notification or authorization requirements through eviCore
  • Review the codes requiring authorization or notification in the Physical medicine section.

Transplants and ventricular assist devices

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33975, 33976, 33979, 33990, 33991, 33993 L8698

Heart Transplants (PDF)

  • 33945

Heart/Lung Transplants (PDF)

  • 33935

Intestinal and Multi-Visceral Transplants (PDF)

  • 44132, 44133, 44135, 44136, 44715, 44720, 44721, 47135, 48554

Islet Cell Transplantation (PDF)

  • G0343, G0341, G0342

Liver Transplants (PDF)

  • 47135

Lung Transplants (PDF)

  • 32851, 32852, 32853, 32854

Pancreas Transplants (PDF)

  • 48554

Stem Cell / Bone Marrow Transplants (PDF)

  • 38205, 38206, 38232, 38240, 38241, 38242

Utilization management

Air Ambulance Transport (PDF)

  • A0430, A0435
  • Pre-authorization is required prior to elective fixed wing 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.