News
Medicare Prior Authorization - List effective 10/1/2023
Date: 08/17/23
Wellcare 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.
Wellcare 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 Online Prior Authorization Tool on our website at WellcareNE.com.
Effective October 1st, 2023, the following are changes to prior authorization requirements:
Service Category |
PA Rule | Services | Procedure Codes |
|---|---|---|---|
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, E0467 | ||
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 |