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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

 



Last Updated: 05/17/2024