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Medicare Prior Authorization Change for October 2023

Date: 08/24/23

List effective October 1, 2023

Sunflower Health Plan requires prior authorization (PA) as a condition of payment for many services. This notice contains information regarding such prior authorization requirements and is applicable to all Medicare products Sunflower offers.

Sunflower 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 physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

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 the Pre Auth Check Tool on our website.

Effective October 1, 2023, the following are changes to prior authorization requirements:

Audiology

  • No PA Required
    • Pure tone audiometry - 0208T, 0209T

Behavioral Health

  • No PA Required
    • Alcohol and/or drug services - H0010, H0011, H0012, H0014, H0016, H0018
    • Assertive community treatment, face-to-face - H0039
    • BH and Community Support Services - H2001, H2012, H2016, H2018, H2020, H2022, H2030, H2034, H2036
    • Crisis intervention mental health services, per hour - S9484, S9485
    • Adaptive behavior treatment - 97157

Breast Reconstruction

  • No PA Required
    • Repair and/or reconstruction - 19357, 19367, 19368, S2068

Cardiovascular

  • PA Required
    • Coronary intravascular lithotripsy (IVL) procedure - 0715T
    • Pacemaker/cardioverter-defibrillator devices and procedures - C1899, G0448
  • No PA Required
    • Device interrogation and analysis - 0418T
    • Transcatheter valve and cardiac procedures - 0483T, 0569T, 0644T

DME & Supplies

  • PA Required
    • Hospital bed and mattress - E0302, E0372, E0462
    • Respiratory systems and supplies - E0440, E046S
    • Patient lifts - E0639
    • Pneumatic & non-pneumatic compressor devices - E0657, E0665, E0666, E0669, E0670, E0672, K1024, K1033
    • Ultraviolet light therapy - E0691, E0694
    • Wheelchairs, power operated vehicles, and accessories - E0983, E0985, E0988, E1004, E1036, E1070, E1084, E1087, E1170, E1222, E1223, E1228, E1239, E1270, E1280, E1296, E1298, E2328, E2341, E2343, E2358, E2362, E2364, E2368, E2369, E2610, E2614, E2625, E2631, E2632, E2633, K0008, K0009, K0011, K0012, K0014, K0015, K0046, K0065, K0098, K0669, K0802, K0807, K0812, K0814, K0815, K0829, K0850, K0851, K0852, K0853, K0860, K0864, K0877, K0878, K0884, K0891, K0898, K0899
    • Nerve stimulating device - K1018
    • Speech generating device/accessory - E2502
    • Automatic external defibrillator - K0606
  • No PA Required
    • Compression burn garment - A6507
    • Hospital bed, mattress, and supplies - E0181, E0182, E0189, E0305, E0310, E0316, E0328
    • Electronic bowel irrigation system - E0350
    • Delivery/installation charges for hemodialysis equipment - E1600
    • Heat, cold, and light therapies - E0202, E0217, E0221
    • Respiratory systems, devices and supplies - A7047, E0435, E0455, E0472, E0500
    • Breast pump, hospital grade, electric - E0604
    • Monitoring equipment - E0619, E0620
    • Functional electrical stimulator - E0770
    • Traction and other orthopedic devices - E0856, E0944
    • Wheelchairs and accessories - E0968, E0969, E0980, E0994, E1014, E1029, E1092, E1093, E1160, E1229, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E2291, E2292, E2293, E2294, E2301, E2324, E2381, E2382, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, K0017, K0018, K0020, K0053, K0105, K0195
    • Blood glucose monitor - E2100, E2102

Evaluation & Management:

  • No PA Required
    • Nursing facility care plan oversight - 99306, 99379
    • Medication therapy management - 99605, 99606, 99607

General Surgery

  • PA Required
    • Repair procedures on the nose - 30410, 30420, 30430, 30520
    • Procedures on the stomach - 43881
    • Procedures on the penis - 54400, 54401, 54405
    • Phrenic nerve stimulation system procedure - 0435T
    • Benign thyroid nodule ablation - 0673T
  • No PA Required, unless managed by a vendor in select markets
    • Removal of abdominal mesh - 11008
    • Removal of skin tags procedures - 11200, 11201
    • Skin color correction - 11920, 11921, 11922
    • Tissue expanders - 11960, 11970, 11971
    • Skin therapies - 15786, 15787, 17360
    • Trigger point injections - 20552, 20553
    • Cranial/facial repairs - 21175, 21181, 21183, 21193, 21230, 21256, 21280
    • Repair procedures on the nose - 30460, 30462, 30560, 30630
    • Transplant related procedures - 32855, 32856, 33933, 33940, 33944, 38206, 38207, 38208, 38209, 38214, 38215, 38230, 47143, 48551, 48552, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50370
    • Repair procedures on the urethra - 52010, 52301, 52343, 53420
    • Excision procedures on the endocrine system - 60212, 60505
    • Procedures on the spine/spinal cord - 22527, 62367, 62368, 62370
    • Procedures on the cardiovascular system - 33952, 36836, 36837
    • Procedures on the spleen - 38129
    • Procedures on the diaphragm - 39599
    • Procedures on the digestive system - 43283, 43772, 43774, 44145, 64595
    • Neurostimulator procedures on the peripheral nerves - 64585

GI Services

  • No PA Required
    • Transnasal EGD - 0652T, 0653T

Gynecology

  • No PA Required
    • Excision/repair of the vulva, vagina - 56625, 57291, 57292
    • Hysterectomy procedures - 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58270, 58275, 58280, 58290, 58291, 58292, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58575, 58951, 58953, 58954, 58956
    • Myomectomy, ovarian/tubal resection - 58545, 58546, 58661, 58720, 58940, 58952

Home Care

  • No PA Required
    • Home care services - S5145, S5150
    • Contracted home health - T1022

Injection Procedures

  • PA Required
    • Percutaneous lumbar intravertebral disc injection - 0627T, 0628T
  • No PA Required
    • Injection of the spine/spinal cord - 62280, 62290, 62291, 62324, 62325, 62326, 62327

Maternity

  • No PA Required
    • Maternity care - 59866, 59897

Medicine Services & Procedures

  • No PA Required, unless managed by a vendor in select markets
    • Instillation, bupivacaine and meloxicam, 1 mg/0.03 mg - C9088
    • Immune globulins, serum or recombinant product – 90283
    • Special otorhinolaryngologic procedures - 92512, 92516, 92520, 92546, 92597, 92607, 92608, 92609, 92610, 92700
    • Neurology testing - 95700, 95803
    • Chiropractic treatment - 98940, 98941, 98942
    • Education and training for patient self-management - 98960

Nutrition

  • No PA Required
    • Medical nutrition therapy – 97804
    • Enteral formulas and additives - B4157, B4158, B4159, B4162, B9006
    • Medical foods for inborn errors of metabolism - S9435

Orthopedics

  • PA Required
    • Insertion sinus tarsi implant - 0335T
    • Sacroiliac joint arthrodesis procedure - 0775T

Ophthalmology

  • No PA Required
    • Open-eye eyelid treatment device - 0563T
    • Other procedures on the cornea - 65765

Orthotics and Prosthetics

  • PA Required
    • Spinal orthotics - L0458, L0468, L0480, L0484, L0632, L0638, L0639, L0640, L0651, L1200, L1300
    • Lower extremity orthotics - E1830, L1690, L1840, L1904, L2000, L2005, L2030, L2034, L2038, L2525, L2627, L2628
    • Upper extremity orthotics - E1802, E1818, E1840
    • Lower extremity prosthetics - K1014, L5010, L5060, L5200, L5505, L5510, L5520, L5535, L5560, L5570, L5600, L5610, L5614, L5628, L5630, L5638, L5639, L5640, L5661, L5682, L5702, L5795, L5818, L5824, L5826, L5830, L5858, L5859, L5930, L5966, L5969, L5982, L5990
    • Upper extremity prosthetics - L6000, L6010, L6020, L6200, L6250, L6320, L6400, L6623, L6628, L6638, L6646, L6647, L6692, L6697, L6704, L6711, L6712, L6883, L6885, L6895, L6900, L6905, L6910, L6920, L6925, L6940, L6945, L6950, L6965, L7405
    • Cochlear device - L8614
    • Orbital prosthetics - L8042
    • Unlisted prosthetics - L8499
  • No PA Required
    • Penile devices - C2622, L7900
    • Spinal orthotics - L0700, L0710
    • Upper extremity orthotics - L0170, L0190, L3671, L3674, L3962
    • Lower extremity orthotics - L0469, L0470, L1000, L1270, L1640, L1730, L1847, L1860, L2126, L2136, L2570, L2580
    • Cochlear implant device components - L8627, L8628, L8629
    • Pretibial shell - L4130
    • Prosthetic fitting, immediate post-surgical - L5400, L5420, L5430
    • Nasal and facial prosthesis - L8040, L8046, V2629
    • Finger prosthetics - L8659

Pain Management

  • PA Required
    • Percutaneous cranial nerves stimulation - 0720T
    • Injection of anesthetic agent (nerve block) - 64450, 64451, 64494
    • Destruction by neurolytic agent - 64624

Pathology and Laboratory

  • PA Required
    • Genetic analysis - 81265, 81266
  • No PA Required
    • Multianalyte assays - 0014M
    • Proprietary laboratory analyses - 0035U, 0040U, 0219U, 0353U
    • Therapeutic drug assays - 80220
    • Genetic analysis - 81224, 81239, 81262, 81316, 81341
    • Multianalyte assays w/algorithmic analyses - 81508, 81511, 81512, 81513, 81514, 81528
    • Chemistry procedures - 82077, 82105, 82397, 82657, 82677, 84163, 84702, 84704, 84999
    • Qualitative or semiquantitative immunoassays - 86152, 86336
    • Postmortem examination - 88025
    • Flow cytometry, cytogenetic studies - 88182, 88230, 88233, 88235, 88237, 88263, 88269, 88291
    • Surgical pathology - 88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, 88377, 88381
    • Reproductive medicine - 89310, 89320, 89321

Pharmacy

  • No PA Required
    • Pharmacy dispensing fee for inhalation drug(s) - Q0513, Q0514
    • Pharmacy compounding and dispensing services - S9430

Professional Services

  • No PA Required
    • Molecular pathology procedure; physician interpretation and report - G0452
    • Hospital observation service and admission - G0378, G0379

Radiology Services                          

  • No PA Required – except when managed by vendor in select markets
    • PET imaging, any site, NOS - G0235
    • ERCP with endomicroscopy - 0397T
    • Quantitative ultrasound tissue characterization - 0690T
    • Fetal MRI - 74713
    • Endocrine system - 78012, 78013, 78014, 78018, 78070, 78071, 78072
    • Bone marrow imaging - 78102
    • Gastrointestinal system - 78201, 78202, 78215, 78216, 78226, 78227
    • Cardiovascular system - 75565, 78434
    • Radiopharmaceutical localization of tumor - 78800, 78804

Radiopharmaceuticals

  • PA Required
    • Lutetium lu 177 vipivotide tetraxetan, therapeutic - A9607
  • No PA Required                   
    • Radiopharmaceutical, diagnostic, not otherwise classified - A4641
    • Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose - A9552
    • Rubidium Rb-82, diagnostic, per study dose - A9555

Skin Substitute

  • PA Required
    • Skin substitute products - Q4199
  • No PA Required
    • Autograft suspension - C1832

Specialty Medications

  • PA Required
    • Injectable Medication - J1950, J2182, J2786, J9214, J9044
    • Intravitreal implant - J7313
    • Hyaluronic injections - J7322, J7328
  • No PA Required
    • Inhalation medications - J7605, J7606, J7626
    • Injectables - J0121, J0572, J0573, J0574, J1750, J1756, J2212, J2440, J1453, J3489, S0039, S0080
    • Other medication - S0091, S0157

Therapy Services

  • No PA Required, unless managed by a vendor in select markets
    • Physical medicine and rehab evaluations - 97164, 97168, 97169, 97170, 97172, 97750
    • Occupational therapy services, qualified occupational therapist - G0129
    • Speech, language, dysphagia screenings - V5362, V5363, V5364
    • Electrical stimulation, (unattended) - G0281, G0282

Wound Care

  • PA Required
    • Active wound care management – PA required after 12 combined wound care visits per calendar year - 97597, 97598, 97602
    • Electrical stimulation and cutaneous wound healing - 0512T
    • Matrix for wound management - A2001, A2002, A2004, A2005, A2007, A2015

Thank you for continuing to provide our Medicare members with high quality and compassionate care.

If you have questions or need specific support, please contact Provider Services at Wellcare By Allwell (Medicare Advantage):

  • HMO 1-855-565-9519
  • HMO D-SNP 1-833-402-6707
  • PPO 1-833-696-0634
  • TTY: 711