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Authorization Requirements Medicare

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Authorization Requirements Medicare EFFECTIVE 05/17/21 FOR MEDICARE The following items always require authorization: Inpatient Services Hospital inpatient admissions All other inpatient admissions (e.g. acute, skilled nursing facility, and rehabilitation) Services rendered at or provided by a non-par provider Covered services that do not have a fee attached Muskuloskeletal Surgery Procedures: Knee/Hip/Shoulder, and Cervical Lumbar Spine o Link to NIA Outpatient Services Potentially experimental, investigational or cosmetic services Home Health Care Prosthetics Power Wheelchairs Partial Hospitalizations for Behavioral Health Hospice Services Radiology Management, Physical Therapy, Occupational Therapy, Speech Therapy, Musculoskeletal Surgery Procedures (MSK), Trigger Point Injections and Interventional Pain Management o Link to NIA Services rendered at or provided by a non-par provider Covered services that do not have a fee attached Chemotherapeutic drugs, symptom management drugs and supportive agents will require authorization when prescribed for a member 18 years of age or older and being used for an oncology related indication. The Gateway Health Provider Portal Procedure Code Lookup Tool below can be used to determine if the medication being administered requires authorization. Miscellaneous J-codes (J3490, J3590, J8499, J8999, J9999) may require authorization on a drug-by-drug basis. The authorization information will not be identified in the Provider Search Tool due to system limitations. Please refer to notifications of authorization requirements posted on the provider update webpage: https://www.gatewayhealthplan.com/provider/medicaid-resources/medicaid-provider-updates. When permanent HCPCS codes are assigned to medications, the lookup tool below will be updated to reflect the authorization requirement. Please utilize the Portal Code Search Tool to research authorization requirements for all other codes currently requiring authorization. The reference list attached outlines codes requiring authorization not included in the services listed above. Attention: Non covered benefits will not be paid unless special circumstances exists. Always review member benefits to determine covered & non-covered services. Authorization does not guarantee payment of claims. A service or supply will be reimbursed by Gateway Health only if it is medically necessary, a covered service, and provided to an eligible member. o The authorization process continues to be subject to the maximum unit and program exception policies. MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 11920 TATTOOING 11950 THERAPY FOR CONTOUR DEFECTS 11954 THERAPY FOR CONTOUR DEFECTS 13152 REPAIR OF WOUND OR LESION 14040 TIS TRNFR F/C/C/M/N/A/G/H/F 14061 SKIN TISSUE REARRANGEMENT 14301 SKIN TISSUE REARRANGEMENT 15040 HARVEST CULTURED SKIN GRAFT 15050 SKIN PINCH GRAFT 15100 SKIN SPLT GRFT TRNK/ARM/LEG 15110 EPIDRM AUTOGRFT TRNK/ARM/LEG 15115 EPIDRM A-GRFT FACE/NCK/HF/G 15120 SKN SPLT A-GRFT FAC/NCK/HF/G 15130 DERM AUTOGRAFT TRNK/ARM/LEG 15135 DERM AUTOGRAFT FACE/NCK/HF/G 15150 CULT SKIN GRFT T/ARM/LEG 15155 CULT SKIN GRAFT F/N/HF/G 15200 SKIN FULL GRAFT TRUNK 15220 SKIN FULL GRAFT SCLP/ARM/LEG 15240 SKIN FULL GRFT FACE/GENIT/HF 15260 SKIN FULL GRAFT EEN & LIPS 15271 SKIN SUB GRAFT TRNK/ARM/LEG 15273 SKIN SUB GRFT T/ARM/LG CHILD 15275 SKIN SUB GRAFT FACE/NK/HF/G 15277 SKN SUB GRFT F/N/HF/G CHILD 15734 MUSCLE-SKIN GRAFT TRUNK 15736 MUSCLE-SKIN GRAFT ARM 15760 COMPOSITE SKIN GRAFT 15770 DERMA-FAT-FASCIA GRAFT 15775 HAIR TRNSPL 1-15 PUNCH GRFTS 15776 HAIR TRNSPL >15 PUNCH GRAFTS 15783 ABRASION TREATMENT OF SKIN MP 15820 REVISION OF LOWER EYELID 15821 REVISION OF LOWER EYELID 15822 REVISION OF UPPER EYELID 15823 REVISION OF UPPER EYELID 15825 REMOVAL OF NECK WRINKLES 15830 Excision, excessive skin and subcutaneous tissue 15832 EXCISE EXCESSIVE SKIN TISSUE MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics 15833 EXCISE EXCESSIVE SKIN LEG 15834 EXCISE EXCESSIVE SKIN TISSUE 15835 EXCISE EXCESSIVE SKIN BUTTCK 15836 EXCISE EXCESSIVE SKIN TISSUE 15837 EXCISE EXCESS SKIN ARM/HAND 15838 EXCISE EXCESS SKIN FAT PAD 15839 EXCISE EXCESSIVE SKIN TISSUE MP 15847 Excision, excessive skin and subcutaneous tissue 15876 SUCTION LIPECTOMY HEAD&NECK 15877 SUCTION LIPECTOMY TRUNK 15878 SUCTION LIPECTOMY UPR EXTREM 15879 SUCTION LIPECTOMY LWR EXTREM 19300 REMOVAL OF BREAST TISSUE 19316 SUSPENSION OF BREAST 19318 REDUCTION OF LARGE BREAST 19324 ENLARGE BREAST 19325 ENLARGE BREAST WITH IMPLANT 19328 REMOVAL OF BREAST IMPLANT 19330 REMOVAL OF IMPLANT MATERIAL 19340 IMMEDIATE BREAST PROSTHESIS 19342 DELAYED BREAST PROSTHESIS 19350 BREAST RECONSTRUCTION 19355 CORRECT INVERTED NIPPLE(S) 19357 BREAST RECONSTRUCTION 19366 BREAST RECONSTRUCTION 19370 SURGERY OF BREAST CAPSULE 19371 REMOVAL OF BREAST CAPSULE 19380 REVISE BREAST RECONSTRUCTION 19396 DESIGN CUSTOM BREAST IMPLANT NIA 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) MP 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) NIA 20561 Needle insertion(s) without injection(s); 3 or more muscles MP 20561 Needle insertion(s) without injection(s); 3 or more muscles 20912 REMOVE CARTILAGE FOR GRAFT 21198 RECONSTR LWR JAW SEGMENT 21235 EAR CARTILAGE GRAFT 21240 RECONSTRUCTION OF JAW JOINT 21335 TREATMENT OF NOSE FRACTURE 22514 PERQ VERTEBRAL AUGMENTATION NIA 22533 Arthrodesis, lateral extracavitary technique; lumbar NIA 22534 Arthrodesis, lateral extracavitary technique; thoracic or lumbar NIA 22548 Arthrodesis, anterior transoral or extraoral technique MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 22551 Arthrodesis, anterior interbody; cervical below C2 NIA 22552 Arthrodesis, anterior interbody; cervical below C2, each additional NIA 22554 Arthrodesis, anterior interbody; cervical below C2 NIA 22558 Arthrodesis, anterior interbody; lumbar NIA 22585 Arthrodesis, anterior interbody; each additional NIA 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) NIA 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) NIA 22600 Arthrodesis, posterior or posterolateral, single level; cervical NIA 22612 Arthrodesis, posterior or posterolateral technique, single level NIA 22614 Arthrodesis, posterior or posterolateral technique, single level NIA 22630 Arthrodesis, posterior interbody technique, single interspace NIA 22632 Arthrodesis, posterior interbody technique, single interspace NIA 22633 Arthrodesis, combined posterior or posterolateral; lumbar NIA 22634 Arthrodesis, combined posterior or posterolateral; each additional NIA 22856 Total disc arthroplasty (artificial disc), anterior approach NIA 22858 Total disc arthroplasty (artificial disc), anterior approach NIA 22861 Revision including replacement of total disc arthroplasty; cervical NIA 22864 Removal of total disc arthroplasty; cervical NIA 23120 Claviculectomy; partial NIA 23125 Claviculectomy; total NIA 23130 Acromioplasty or acromionectomy, partial NIA 23405 Tenotomy, shoulder area; single tendon NIA 23410 Repair of ruptured musculotendinous cuff open; acute NIA 23412 Repair of ruptured musculotendinous cuff open; chronic NIA 23415 Coracoacromial ligament release, with or without acromioplasty NIA 23420 Reconstruction of complete shoulder cuff avulsion, chronic NIA 23430 Tenodesis of long tendon of biceps NIA 23450 Capsulorrhaphy, anterior; Putti-Platt procedure/Magnuson NIA 23455 Capsulorrhaphy, anterior; with labral repair NIA 23460 Capsulorrhaphy, anterior, any type; with bone block NIA 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer NIA 23465 Capsulorrhaphy, glenohumeral joint, posterior, w or w/o bone block NIA 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional NIA 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty NIA 23472 Arthroplasty, glenohumeral joint; total shoulder NIA 23473 Revision of total shoulder arthroplasty; humeral or glenoid NIA 23474 Revision of total shoulder arthroplasty; humeral and glenoid NIA 23700 Manipulation under anesthesia, shoulder joint 24305 ARM TENDON LENGTHENING 25107 REMOVE WRIST JOINT CARTILAGE 25111 REMOVE WRIST TENDON LESION 25447 REPAIR WRIST JOINTS MP – Medical Policy NIA – Requests via NIA RX – Requests via Pharmacy OA – Oncology Analytics NIA 27096 Injection procedure for sacroiliac joint, anesthetic/steroid NIA 27130 Arthroplasty, acetabular and proximal femoral prosthetic NIA 27132 Conversion of previous hip surgery to total hip arthroplasty NIA 27134 Revision of total hip arthroplasty; both components NIA 27137 Revision of total hip arthroplasty; acetabular component only NIA 27138 Revision of total hip arthroplasty; femoral component only NIA 27332 Arthrotomy, with excision of semilunar cartilage knee NIA 27333 Arthrotomy, with excision of semilunar cartilage knee NIA 27403 Arthrotomy with meniscus repair, knee NIA 27405 Repair, primary, torn ligament and/or capsule, knee; collateral NIA 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate NIA 27409 Repair, primary, torn ligament and/or capsule, knee NIA 27412 Autologous chondrocyte implantation, knee NIA 27415 Osteochondral allograft, knee, open NIA 27416 Osteochondral autograft(s), knee, open NIA 27418 Anterior tibial tubercleplasty NIA 27420 Reconstruction of dislocating patella NIA 27422 Reconstruction of dislocating patella; with extensor realignment NIA 27424 Reconstruction of dislocating patella; with patellectomy NIA 27425 Lateral retinacular release, open
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