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Medicare Prior Authorization

List effective 1/1/2021

Allwell from MHS Health Wisconsin (Allwell) requires prior authorization 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 Allwell.

Allwell 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 ordering physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria.

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

Effective January 1st, 2021, Prior Authorization will be required for the following services:

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.

Service Category

Services/Procedures

Comments

Acupuncture

An alternate form of medicine in which thin needles are inserted into the body.   Medicare doesn't cover acupuncture (including dry needling) for any condition other than chronic low back pain.  Limit to 20 visits

Prior Auth Required:
Allwell Medicare Advantage from MHS Health Wisconsin


Contracted Providers:

Visit ashlink.com
Non-Contracted providers:
Call 877-248-2746

Ambulance Non-emergent Fixed Wing

Requires prior authorization before transport

 

Behavioral Health Services

  • Day Treatment
  • Electroconvulsive Therapy (ECT)
  • Inpatient Psychiatric
  • Intensive Outpatient Therapy
  • Neuropsychological Testing
  • Partial hospitalization
  • Psychological Testing
  • Substance Use Disorder Treatment/Rehabilitation

 

 

 

 

 

 

 

 

Bronchial Thermoplasty

Outpatient procedure for the treatment of asthma

 

Chiropractor Services Medicare coverage for chiropractic services extends only to treatment by means of manual manipulation of the spine to correct a subluxation, provided such treatment is reasonable and medically necessary Contracted Providers:
Visit ashlink.com
Non-Contracted providers:
Call 877-248-2746
Clinical Trials: Notification Only A clinical trial is one type of clinical research that follows a pre-defined plan or protocol  
Cochlear Implants & Surgery Provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea  
Cosmetic Procedures/Dermatology

Includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member Including, but not limited to the following:

  • Chemical exfoliation, electrolysis
  • Dermabrasion /chemical peel
  • Laser treatment
  • Skin injections and implants
 
Drug Testing Quantitative tests for drugs of abuse  
Durable Medical Equipment 
  • Ambulatory Infusion Pumps
  • BIPAP
  • Bone Growth Stimulator
  • Continuous Glucose Monitor
  • Hospital Bed/Mattress
  • Implantable Neurostimulator
  • Lift Devices including Hoyer
  • Lymphedema Pumps and Supplies
  • TENS Units
  • Vagus Nerve Stimulator
  • Ventilators
  • Wheelchairs, Custom
  • Wheelchairs, Power
  • Wound Vacuum (Negative Pressure) Devices
 
Enhanced External Counter-pulsation (EECP) The noninvasive outpatient treatment for patients with coronary artery disease (CAD)  
Experimental/Investigational Services Any item or service potentially considered investigational or experimental must be authorized in advance  
Gender Reassignment General term to describe a surgery or surgeries that affirm a person's gender identity  

Genetic Counseling and Testing

Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins  
Infertility Drug Therapy, Testing, Treatment  

Home Health Services

  • Home Health Aide
  • Occupational Therapy
  • Physical Therapy
  • Skilled Nursing Visits
  • Social Work Visits
  • Speech Therapy
 
Hospice: Notification only Home or Inpatient  

Hospital Admission

  • Acute Inpatient Hospital
  • Inpatient Rehabilitation Hospital
  • Long Term Acute Care Hospital (LTAC)
  • Skilled Nursing Facility (SNF)
 
Hyperbaric O2 Therapy Includes HBO therapy administered in a chamber  

Neuropsychological Testing

Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning

 

Nutritional Supplements and/or services

Formula administered via a enteral feeding tube

 

Observation Stay

Prior Authorization required if >48 hours

 

Orthotics/Prosthetics

Prosthetic devices needed to replace a body part or function

Limited coverage options for orthotic shoes and devices, including artificial limbs and eyes as well as braces for arms, legs, back, or neck, penile prosthetics
 

 
  • Outpatient Therapy
  • Occupational Therapy
  • Physical Therapy
  • Speech-Language Therapy
Therapeutic treatment: as a remedial treatment of mental or bodily disorder or an agency (as treatment) designed or serving to bring about rehabilitation or social adjustment
 
Requires authorization after 12 combined visits
Pain Management
  • Facet Injections
  • Median Branch Block
  • Radio Frequency Ablation
  • Sacroiliac joint injection (SI)
  • Trigger Point
 
Part B Drugs   See attached Appendix A 
Radiation Therapy
  • Intensity modulated radiotherapy (IMRT)
  • Neutron beam therapy
  • Proton beam therapy
  • Stereotactic radiotherapy
 
Radiology
  • Cardiac Imaging
  • CT
  • MRA
  • MRI, MRA, PET Scan, CT, Cardiac Imaging
  • PET
All Health Plans Excluding Allwell Medicare Advantage from MHS Health Wisconsin visit www.radmd.com
 
Sleep Studies
  • Surgery and treatment
  • Hospital Sleep Study
 
Surgeries, regardless of place of service
  • Abortion
  • Bariatric Surgery
  • Blepharoplasty
  • Breast Augmentation (except following mastectomy)
  • Breast Reduction
  • Capsule Endoscopy
  • Chondrocyte Implants
  • Cochlear Implant
  • Facial Osteotomy
  • Hysterectomy
  • Joint Replacements
  • Mastectomy for Gynecomastia
 
Surgeries, regardless of place of service continued
  • Oral Surgery -- Temporomandibular Joint Surgery
  • Otoplasty
  • Reconstructive and Plastic Surgery
  • Rhinoplasty
  • Sacral Nerve Neuromodulation
  • Septoplasty
  • Spinal Surgeries including Fusion, Stabilization, Discectomy
  • Uvulopalatopharyngoplasty/
    Uvolopharyngoplasty
  • Veins (ablation, ligation, stripping, sclerotherapy)
  • X-Stop: Spinal Surgery
 
Transplants All transplant evaluations and procedures, including but not limited to evaluation, transplant consult visits, HLA typing, donor search and transplant procedure