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 Essentials: 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, 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).

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. 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 review

Timeframe

Additional time allowed for review if additional information is needed:

Urgent

72 hours

None

Standard initial

14 calendar days

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

Concurrent

24 hours
Effective September 1, 2022: Must notify within 24 hours for newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission.
Exception:
Maternity notifications are required on day 6.

72 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.

We will respond to your notification with the date clinical records are due. If you have granted our clinical team access to your electronic medical records (EMR) system, please ensure these records are available in your EMR system.

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.

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.

  • Applied behavior analysis (ABA) therapy:
    • Procedure codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
    • Procedure codes 97151, 97152, and 0362T: Pre-authorization Is not required when 97151, 97152, and 0362T are used for initial ABA assessments, but pre-authorization is required when 97151, 97152, and 0362T are used for ABA reassessments
    • Pre-authorization for medical necessity is not required for Medicare members under the age of 18, but Medicare-approved provider requirements still apply
  • 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 and forms 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 study

Contact 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

Bone Growth Stimulators (Osteogenic Stimulation) (PDF)

  • 20979, E0747, E0760

Commode Chairs with Seat Lift Mechanism (PDF)

  • E0170, E0171

External Insulin Infusion Pumps (PDF)

  • E0784

Electrical Stimulation and Electromagnetic Therapy Devices (PDF)

  • 0278T, 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

Definitive Lower Limb Prostheses (PDF)

  • Effective December 1, 2022: L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987

Negative Pressure Wound Therapy in the Outpatient Setting (PDF)

  • 97605, 97606, 97607, 97608, A6550, A7000, E2402, K0743
  • The policy requires an initial pre-authorization for a 1-month therapeutic trial and then after one month, another pre-authorization for continuation is required demonstrating improvement in the wound.

Noninvasive Ventilators in the Home Setting (PDF)

  • E0466

Pneumatic Compression Devices (PDF)

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

Power Wheelchairs (PWCs) (PDF)

  • K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Power Wheelchairs - Group 2 and Group 3

  • K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843

Powered Exoskeleton for Ambulation (PDF)

  • K1007

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

  • K1014, L2006, 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.

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, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 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, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 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, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81347, 81348, 81349, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 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, G9143, 0009U, 0016U, 0017U, 0023U, 0027U, 0031U, 0032U, 0046U, 0049U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0080U, 0154U, 0155U, 0156U, 0177U, 0218U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0338U

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, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 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, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 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, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81347, 81348, 81349, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 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, 81419, 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, 81513, 81514, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81538, 81539, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 0011M, 0017M, 0005U, 0018U, 0019U, 0022U, 0026U, 0029U, 0030U, 0033U, 0034U, 0037U, 0045U, 0047U, 0048U, 0068U, 0086U, 0089U, 0090U, 0101U, 0109U, 0111U, 0112U, 0118U, 0129U, 0131U, 0133U, 0134U, 0140U, 0141U, 0142U, 0169U, 0171U, 0172U, 0179U, 0202U, 0223U, 0225U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0250U, 0288U, 0306U, 0307U, 0311U, 0323U, 0326U, 0327U, 0329U, 0330U, 0331U, 0334U, 0340U, 0343U, 0345U, 0352U, G0327

Physical Medicine

  1. Review this entire page for similar services that require pre-authorization
  2. Verify member benefits, eligibility and pre-authorization requirements on the Availity Portal
  3. Determine whether a member's plan participates in this program by using the electronic authorization tool on the Availity Portal
  4. Obtain or verify an authorization with eviCore:

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

  • Determine whether a member's plan participates in this program by using the electronic authorization tool on the Availity Portal.
  • Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF) for enrolled dependents aged 17 and younger.
  • Rehabilitative care (PT, OT, ST) ordered by home health and performed during home health care visits does not require review by eviCore, but does require pre-authorization from Regence.
  • We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 95851, 95852, 96105, 97012, 97016, 97018, 97022, 97024, 97028, 97032, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97129, 97130, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283, S9152

Pain management

  • Determine whether a member's plan participates in this program by using the electronic authorization tool on the Availity Portal.
  • We require authorization from eviCore for these codes: 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, 72285, 72295, G0259, G0260

Joint management

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine whether a member's plan participates in this program, use the electronic authorization tool on the Availity Portal
  • We require authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27130, 27132, 27134, 27137, 27138, 27332, 27333, 27334, 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27570, 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

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine whether a member's plan participates in this program, use the electronic authorization tool on the Availity Portal
  • We require authorization from eviCore for these codes: 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, 63185, 63190, 63191, 63197, 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:

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.

To determine whether your patient's plan participates in this program, use the electronic authorization tool on the Availity Portal.

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, 71271, 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, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 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, 0042T, 0501T, 0502T, 0503T, 0504T, 0648T, 0649T

Transplants and ventricular assist devices

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33975, 33976, 33979, 33990, 33991, 33993, 33995, 33997, 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)

  • 0584T, 0585T, 0586T, G0343, G0341, G0342

Liver Transplants (PDF)

  • 47135

Lung Transplants (PDF)

  • 32851, 32852, 32853, 32854

Pancreas Transplants (PDF)

  • 48554

Stem Cell and Bone Marrow Transplantation (PDF)

  • 38205, 38206, 38232, 38240, 38241, 38242, C9782

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; clinical documentation will be requested, if needed, upon receipt of the electronic claim.