New prior authorization requirements for Individual Exchange plans

Starting March 1, 2022, the following clinical categories will require prior authorization for Individual Exchange plans:

  • Arthroscopy
  • Category III: Emerging and experimental
  • Community support
  • Durable medical equipment
  • Enteral and parenteral feeding
  • Gender dysphoria treatment with diagnosis
  • Hearing aids and services
  • Home health
  • Infertility and infertility with diagnosis
  • Medical injectables
  • Medicine services and procedures
  • Pain management
  • Potentially cosmetic
  • Private duty nursing

See below to view the list of applicable codes.

Expand All add_circle_outline
CPT® code Description
SBRT/SRS

29820

ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY PART

Adding prior authorization for medical necessity in all states

29821

ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY COMPLT

Adding prior authorization for medical necessity in all states

29830

ARTHROSCOPY ELBOW DIAG W/WO SYNOVIAL BIOPSY SPX

Adding prior authorization for medical necessity in all states

29835

ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL 

Adding prior authorization for medical necessity in all states

29836

ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE

Adding prior authorization for medical necessity in all states

CPT® code Description
SBRT/SRS

0314T

LAPS RMVL VGL ARRY & PLS GEN

Adding prior authorization in all states

0315T

RMVL VAGUS NERVE PLS GEN

Adding prior authorization in all states

CPT® code Description
SBRT/SRS

T1024

Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter

Adding prior authorization in IL

H0040

Assertive community treatment program, per diem

Adding prior authorization in IL

H0037

Community Psychiatric Supportive Treatment program, Per diem

Adding prior authorization in IL

CPT® code Description
SBRT/SRS

E2360

Power wheelchair accessory, 22 NF nonsealed lead acid battery, each

Adding prior authorization to MD

E2362

Power wheelchair accessory, group 24 nonsealed lead acid battery, each

Adding prior authorization to MD

E2364

Power wheelchair accessory, U-1 nonsealed lead acid battery, each

Adding prior authorization to MD

E2372

Power wheelchair accessory, group 27 nonsealed lead acid battery, each

Adding prior authorization to MD

K0800

Power operated vehicle, group 1 standard, patient weight capacity up to and including
300 pounds

Adding prior authorization to MD

K0801

Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds

Adding prior authorization to MD

K0802

Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds

Adding prior authorization to MD

K0812

Power operated vehicle, not otherwise classified

Adding prior authorization to MD

K0813

Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds

Adding prior authorization to MD

K0815

Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds

Adding prior authorization to MD

K0898

POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED

Adding prior authorization to TN, VA and MD

K0820

Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Adding prior authorization to TN, VA and MD

K0822

Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Adding prior authorization to TN, VA and MD

K0823

Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including
300 pounds

Adding prior authorization to TN, VA and MD

K0825

Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds

Adding prior authorization to TN, VA and MD

K0830

Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Adding prior authorization to TN, VA and MD

K0831

Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds

Adding prior authorization to TN, VA and MD

K0835

Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Adding prior authorization to TN, VA and MD

K0837

Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

Adding prior authorization to TN, VA and MD

CPT® code Description
SBRT/SRS

B4150

ENTRL FRMLA CATEG I SEMI-SYN PROTEIN 100 CAL=1U

Adding prior authorization to all states

CPT® code Description
SBRT/SRS

58720

Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

Adding prior authorization to AL

CPT® code Description
SBRT/SRS

V5252

Hearing aid, digitally programmable, binaural, ITE

Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX

V5253

Hearing aid, digitally programmable, binaural, ITE

Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX

V5298

Hearing aid, not otherwise classified

Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX

V5299

Hearing service, miscellaneous

Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX

CPT® code Description
SBRT/SRS

T1001

Nursing assessment/evaluation

Adding prior authorization to OK

T1004

Services of a qualified nursing aide, up to 15 minutes

Adding prior authorization to OK

S9122

HOME HEALTH AIDE/CNA CARE/HOME/HOUR

Adding prior authorization to OK, AZ and TN

CPT® code Description
SBRT/SRS

58760

FIMBRIOPLASTY

Adding prior authorization to AL, AZ, FL, GA, LA,MI, NC, OK, TN, TX, VA, WA

89260

SPERM ISOLATN; SIMPL PREP-INSEM/DX W/SEMEN ANAL

Adding prior authorization to AL, AZ, FL, GA, LA,MI, NC, OK, TN, TX, VA, WA

89261

SPERM ISOLATN; CMPLX PREP-INSEM/DX W/SEMEN ANAL

Adding prior authorization to AL, AZ, FL, GA, LA,MI, NC, OK, TN, TX, VA, WA

S4027

STORAGE OF PREVIOUSLY FROZEN EMBRYOS

Adding prior authorization to MD and IL

S4040

MON & STOR CRYOPRESRV EMBRYOS 30 DA

Adding prior authorization to MD and IL

S4042

MANAGEMENT OF OVULATION INDUCTION PER CYCLE

Adding prior authorization to MD and IL

S4017

INCPL CYCL TX CANCELD PRIOR TO STIM

Adding prior authorization to MD and IL

S4018

FROZEN EMBRYO TRANSFER PROCEDURE CANCELLED BEFORE TRANSFER, CASE RATE

Adding prior authorization to MD and IL

S4020

IN VITRO FERTILIZATION PROCEDURE CANCELLED BEFORE ASPIRATION, CASE RATE

Adding prior authorization to MD and IL

S4021

IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATE

Adding prior authorization to MD and IL

58770

SALPINGOSTOMY (SALPINGONEOSTOMY)

Adding prior authorization to AL

CPT® code Description
SBRT/SRS

S0122

Injection, menotropins, 75 IU

Adding prior authorization to MD and IL

S0126

Injection, follitropin alfa, 75 IU

Adding prior authorization to MD and IL

S0128

Injection, follitropin beta, 75 IU

Adding prior authorization to MD and IL

S0132

Injection, ganirelix acetate, 250 mcg

Adding prior authorization to MD and IL

CPT® code Description
SBRT/SRS

96130

Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed, first hour

Adding prior authorization to all states

96131

Psychological testing evaluation services, by physician or other qualified health care professional,
each additional hour

Adding prior authorization to all states

96136

Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, 2 or more tests, any method, first 30 minutes

Adding prior authorization to all states

96137

Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, 2 or more tests, any method, each additional 30 minutes

Adding prior authorization to all states

96138

Psychological or neuropsychological test admin and scoring by technician, 2 or more tests,
any method, first 30 minutes

Adding prior authorization to all states

96139

Psychological or neuropsychological test admin and scoring by technician, 2 or more tests,
any method, each additional 30 minutes

Adding prior authorization to all states

CPT® code Description
SBRT/SRS

11981

Insertion of drug delivery implant device

Adding prior authorization to all states

CPT® code Description
SBRT/SRS

19300

MASTECTOMY FOR GYNECOMASTIA

Adding prior authorization to MD

15847

EXCIS, XS SKIN AND SUBCUT TISSUE ABDOMINOPLASTY (LIST SEPARATELY)

Adding prior authorization to all states

CPT® code Description
SBRT/SRS

T1000

PRIVATE DUTY/INDEPENDEND NURSING LICENSED UP TO 15 MIN

Adding prior authorization to VA

T1002

RN SERVICES, UP TO 15 MINUTES

Adding prior authorization to MD and VA

T1003

LPN/LVN SERVICES, UP TO 15 MINUTES

Adding prior authorization to MD and VA

Questions?

Call Provider Services at 888-478-4760.

CPT® is a registered trademark of the American Medical Association.
PCA-1-21-04105-E&I-News