Medicare Prior Authorization
Date: 10/30/20
Allwell from Sunflower Health Plan requires prior authorization as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Allwell from Sunflower Health Plan.
Allwell from Sunflower Health Plan is committed to delivering cost effective quality care to our 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.
Effective January 1, 2021, Prior Authorization will be required for the following services:
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 see Online Prior Authorization Tool.
| Service Category | Services/Procedures | Comments |
|---|---|---|
| Acupuncture | 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 | Prior Auth Required:
Non-Contracted providers: Call (800) 972-4226 |
| Ambulance Nonemergent Fixed Wing | Requires prior authorization before transport | |
| Behavioral Health Services |
| |
| Bronchial Thermoplasty | Outpatient procedure for the treatment of asthma | |
| 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 | Prior Auth Required:
Contracted Providers: |
| Clinical Trials: Notification Only | A clinical trial is one type of clinical research that follows a pre-defined plan or protocol | |
| Cochlear Implants & Surgery | Provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea | |
| Cosmetic Procedures/Dermatology | 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:
| |
| Drug Testing | Quantitative tests for drugs of abuse | |
| Durable Medical Equipment (DME) |
| |
| Enhanced External Counterpulsation (EECP) | The noninvasive outpatient treatment for patients with coronary artery disease (CAD) | |
| Experimental/Investigational Services | Any item or service potentially considered investigational or experimental must be authorized in advance | |
| Gender Reassignment | General term to describe a surgery or surgeries that affirm a person's gender identity | |
| Genetic Counseling and Testing | Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins | |
| Infertility | Drug Therapy, Testing, Treatment | |
| Home Health Services |
| |
| Hospice: Notification only | Home or Inpatient | |
| Hospital Admission |
| |
| Hyperbaric O2 Therapy | Includes HBO therapy administered in a chamber | |
| Neuropsychological Testing | Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning | |
| Nutritional Supplements and/or services | Formula administered via a enteral feeding tube | |
| Observation Stay | Prior Authorization required if >48 hours | |
| Orthotics/Prosthetics |
| |
Outpatient Therapy
| 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 | Requires authorization after 12 combined visits |
| Pain Management |
| |
| Part B Drugs | See Appendix A (Excel) | |
| Radiation Therapy |
| |
| Radiology |
| All Health Plans Excluding Allwell Medicare Advantage from MHS Health Wisconsin visit www.radmd.com |
| Sleep Studies |
| |
| Surgeries, regardless of place of service |
| |
| Surgeries, regardless of place of service continued |
| |
| Transplants | All transplant evaluations and procedures, including but not limited to evaluation, transplant consult visits, HLA typing, donor search and transplant procedure |