News

Ambetter Prior Authorization Change Summary

Date: 05/16/23

Ambetter 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 Ambetter products offered by Ambetter.

Ambetter 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.

Effective June 1^st, 2023, the following are changes to prior authorization requirements:

Behavioral Health

PA Rule	Services	Procedure Codes
No PA Required	BH counseling	H0007, H2011, S9484

Breast reconstruction

PA Rule	Services	Procedure Codes
PA Required	Mastectomy, Reconstruction Breast	19300, 19330
PA Required Unless Billed with Breast Cancer Diagnosis	Breast prosthesis	L8031

Cardiovascular

PA Rule	Services	Procedure Codes
PA Required	Insertion/removal of Cardiac Rhythm Monitor	33285
PA Required	Revascularization	37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231
PA Required	Vascular embolization	37799
PA Required	Wireless Pressure Sensor	C2624
PA Required	External circulatory counterpulsation	G0166

DME

PA Rule	Services	Procedure Codes
PA Required	Osteogenesis stimulator	E0749
PA Required	Wheelchairs, power operated vehicles, and accessories	E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624, K0813
PA Required	Supplies for home delivery of infant	S8415
PA Required	Electrical Nerve Stimulator	K1023
PA Required	Non-Pneumatic Compression	K1024, K1025
PA Required	Whirlpool tub Walk In	K1003
No PA Required	Infusion Pumps	B9002, E0781, K0455
No PA Required	Wheelchair and accessories	E2611, K0001
No PA Required	Respiratory equipment	E0550, E0565

Gastroenterology

PA Rule	Services	Procedure Codes
PA Required	GI capsule transit and pressure measurement	91112

Home care

PA Rule	Services	Procedure Codes
PA Required	Home Care Services	0551, S5165, S5170, S5175, S9110, S9122, T1022, T1028
PA Required	Home therapy	G2168, G2169, S5180, S5181
PA Required	Chore Services	S5120, S5121
PA Required	Home repairs for hemodialysis	A4870, A4890
PA Required	Respite Care Services- Home	S5150, S5151, S9125
PA Required	Foster Care	S5140, S5141, S5145, S5146
PA Required	Attendant and Companion Care Services	S5125, S5126, S5130, S5131, S5135, S5136
PA Required	Care Management Home Visit	G0076, G0077, G0078, G0079, G0080, G0081, G0082, G0083, G0084, G0085, G0086, G0087
	Pregnancy Home Services	S9208, S9209, S9211, S9212, S9213, S9214

Laboratory

PA Rule	Services	Procedure Codes
PA Required	Genetic analysis/studies, surgical pathology procedures	81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88377

Orthopedic

PA Rule	Services	Procedure Codes
PA Required	Procedures lower extremities	28285, 28299
PA Required	Spine Procedures	62264, 62350, 62362, 63650, 63655, 63685
PA Required	Endoscopy Wrist	29848

Orthotic & Prosthetics

PA Rule	Services	Procedure Codes
PA Required	TLSO Orthotic	L0464

Other Medical Items

PA Rule	Services	Procedure Codes
PA Required	Health club membership, annual	S9970
PA Required	Waiver Services	T1020, T2012, T2013, T2014, T2015, T2016, T2017, T2020, T2021, T2030, T2031, T2032, T2033, T2035

Pain management

PA Rule	Services	Procedure Codes
PA Required	Trigger Point Injection	20552, 20553
PA Required	Sacroiliac Injection	27096, G0260
PA Required	Nerve Block	64490, 64491, 64492, 64493, 64494, 64495
PA Required	Neurostimulator implantation	64555, 64561, 64566, 64590
PA Required	Destruction by Neurolytic Agent	64620, 64624, 64625, 64633, 64634, 64635,64636, 64640, 64650, 64680, 64681
No PA Required	Transversus abdominis plane (TAP) block	64486, 64488
No PA Required	Destruction by neurolytic agent	64632

Preventive

PA Rule	Services	Procedure Codes
No PA Required	Developmental and behavioral screening	96110, 96112

Professional Services

PA Rule	Services	Procedure Codes
PA Required	Plan of Care Management	G0162
PA Required	Respite Care Services not in home	H0045
PA Required	Collection of alcohol and drug testing	H0048
No PA Required	Hospitalist Services	S0310

Radiology Treatments

PA Rule	Services	Procedure Codes
PA Required	Ablation of liver tumor	47382
PA Required	Stereotactic radiosurgery	77372, 77373, G0339, G0340

Skin substitute

PA Rule	Services	Procedure Codes
PA Required	Skin substitute products	Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Sleep Medicine

PA Rule	Services	Procedure Codes
No PA Required	Home sleep testing	95800, 95806