Medicare Prior Authorization Change Summary
Date: 05/12/22
Wellcare Oklahoma 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 offered by Wellcare Oklahoma.
Wellcare Oklahoma 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 Online Prior Authorization Tool on Wellcare Oklahoma website at www.oklahomacompletehealth.com/providers/preauth-check/medicare-pre-auth.html
Effective July 1st, 2022, the following are changes to prior authorization requirements
Service Category |
Change | Services | Procedure Codes |
Anesthesia | Add PA | Anesthesia for Spine Manipulation or Closed Proc | 00640 |
Dermatology | Add PA | Skin Tag Removal | 11200, 11201 |
Add PA | Benign Lesion Excision | 11451 | |
Surgical | Add PA | Skin Substitutes & Biologicals | 15271, 15273, 15274,15275, 15277, 15278, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4110, Q4116, Q4121, Q4122, Q4124, Q4126, Q4128, Q4132, Q4133, Q4137, Q4138, Q4148, Q4151, Q4153, Q4154, Q4155, Q4158, Q4159, Q4160, Q4161, Q4163, Q4169, Q4178, Q4183, Q4186, Q4187, Q4195, Q4196, Q4197 |
Add PA | Breast Reconstruction | 19357, 19380 | |
Add PA | Flap Procedures | 15600, 15620, 15630, 15650, 15730, 15731, 15733, 15734, 15736, 15738 | |
Add | Suction Assisted Lipectomy | 15877, 15879 | |
Add PA | Blepharoplasty (Lower Eyelid) | 15820 | |
Add PA | Autogenous Rib Cartilage Graft | 21230 | |
Add PA | Temporomandibular joint treatment | 21240, 21242, 21243 | |
Add PA | Malar Augmentation | 21270 | |
Add PA | Unlisted Procedures | 21299, 21899, 41899, 60699 | |
Add PA | Hernia Repair | 49560, 49565, 49652, 49653, 49654, 49656, 49657 | |
Orthopedic | Add PA | Procedures of Upper Extremities | 23405, 23406, 23430, 23485, 24301, 24305, 24341, 24342, 24343, 24344, 24357, 24359, 25111, 25112, 25115, 25118, 25310, 25320, 26480, 26483, 26485, 26498, 29805, 29806, 29820, 29821, 29822, 29823, 29824, 29825, 29828, 29834, 29837, 29838, 29844, 29846 |
Add PA | Procedures of Lower Extremities | 27310, 27380, 27385, 27620, 27696, 27698, 27871, 29891, 29892, 29894, 29895, 29897, 29898 | |
Add PA | Procedures of the foot or toes | 28008, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28306, 28308, 28312 | |
Add PA | Endoscopy (Foot, Wrist) | 29848, 29893 | |
Add PA | Unlisted Procedures | 23929, 27599, 28899, 29799 | |
Pulmonology | Add PA | Unlisted Pulmonary Service | 94799 |
Cardiac | Add PA | Cardiac Monitor Insertion | 33285 |
Add PA | Endovenous Ablation | 36473 | |
Add PA | Endovascular Revascularization | 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231 | |
Add PA | Vascular Embolization and Occlusion | 37241, 37242, 37243, 37244 | |
Add PA | Unlisted Vascular Surgery | 37799 | |
Add PA | Intracardiac Catheter Ablation | 93653, 93654, 93656 | |
ENT | Add PA | Sinus Procedures | 30130, 30140, 30560 |
Add PA | Nasal/Sinus Endoscopy | 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31298 | |
Add PA | Palatopharyngoplasty | 42145 | |
Add PA | Osseointegrated Implant | 69714 | |
Add PA | Unlisted ENT Procedure | 30999, 31299, 92700 | |
Gastroenterology | Add PA | Laparoscopy Procedures | 43280, 43281, 43282, 43283 |
Add PA | Unlisted Procedures | 43289, 43499, 43659, 44238, 44799, 44979, 45399, 45999, 46999, 47379, 49329, 49659, 49999 | |
Add PA | Cholecystectomy | 47562, 47563, 47600 | |
Add PA | Exploratory Laparotomy | 49000 | |
Urology | Add PA | Prostrate Procedure | 53850, 53854, 53899, 55899 |
Add PA | Penile Prosthesis | 54408, 54410, 54416 | |
Add PA | Laparoscopy Surgery (Prostrate) | 55866 | |
Neurology | Add PA | Neurostimulators Procedures | 61885, 61886, 64568, 64575, 64999 |
Add PA | Neuroplasty Procedures | 64704, 64708, 64716, 64718, 64719, 64721 | |
Add PA | Sinusoidal Vertical Axis Rotational Testing | 92546 | |
Add PA | EEG/VEEG | 95700, 95711, 95712, 95713, 95714, 95715, 95716 | |
Ophthalmology | Add PA | Corneal Procedures/Transplant | 65730, 56750, 65755, 65756, 65757, 65770 |
Add PA | Glaucoma Procedures/Surgery | 65855, 66170, 66172, 66183, | |
Add PA | Cataract Procedures | 66820, 66821, 66825, 66830, 66840, 66850, 66852, 66940, 66982, 66983, 66984, 66985, 66986, 66987, 66988 | |
Add PA | Repair Procedures of Eye | 67228, 67255, 67912, 67961, 67966, 68761 | |
Add PA | Unlisted Ophthalmological Service/Procedure | 67999, 92499 | |
Diagnostic radiology | Add PA | Thyroid/Parathyroid Imaging | 78012, 78013, 78014, 78018, 78070, 78071, 78072 |
Add PA | Bone Marrow Imaging | 78102 | |
Add PA | Liver/Spleen & Gallbladder Imaging | 78201, 78202, 78215, 78216, 78226, 78227 | |
Add PA | Radiopharmaceutical Localization of Tumor | 78800, 78802, 78803, 78830, 78831, 78832 | |
Add PA | Unlisted Procedure | 78999 | |
Laboratory | Add PA | Genetic Analysis Procedures | 81245, 81246, 81261, 81263, 81264, 81310, 81315, 81340, 81342 |
Add PA | Engraftment Analysis | 81267, 81268 | |
Add PA | Chronic HCV assay | 81596 | |
Add PA | Bone Marrow Culture | 88237 | |
Behavioral Health | Add PA | Transcranial Magnetic Stimulation | 90867 |
Miscellaneous | Add PA | Unlisted Special Service, Procedure, or Report | 99199
|
Part B Drugs | Add PA | Medical Injectables | C9077, C9081, J2506, J2597, J2794, Q2054, Q2055, Q5123 |
Add PA | Inhalation Solutions | J7605, J7606, J7626 | |
Add PA | CAR-T Therapy | 0537T, 0539T, 0540T |