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 1^st, 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